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SOAP NOTEName:N.A.Date:18 March 2019Time: 1400Age:56Sex:FemaleSUBJECTIVECC: Pt. states “her lower back hurts and she is having some vaginal itching” HPI: The patient presents to the clinic during “sick call” with complaints of her lower back pain, trouble urinating and vaginal itching. The trouble urinating started about 4 or 5 days ago. Pt. states, “I went to the bathroom the other night and it started hurting and burning.” “My back also started to hurt around the same time.” No history of surgeries. Pt. states “I have had a UTI before” Medications:No prescribed medicationsOTC/HerbalAshwagandhaGABAMelatoninCalciumPMHAllergies: NKDAMedication Intolerances: NoneChronic Illnesses:NoneMajor Traumas:NoneHospitalizations/SurgeriesPregnancy (1992)Pregnancy (1988)Appendectomy (1987)Other:Immunizations: Up to date. Pt received influenza for this season, and recently received TDaP. Environmental Hazards: Not assessedDiet: Drinks coffee and tea and states she “attempts to eat healthy”.
Family HistoryNot Assessed
Social HistoryDenies tobacco usage; denies ETOH; denies illicit drug usage.Pt is not in a relationship and is not sexually active at this time.Review of SystemsGeneral Pt denies fever, chills, decreased energy levelsCardiovascularNo c/o chest pain, palpitations, reported murmurs, or edema.SkinNo reports of flushing, rashes, excessive dryness. RespiratoryNo reports of cough, shortness of breath, wheezing, ordyspnea. EyesPt wears corrective lenses. Denies excessive tearing, floaters, or other visual disturbances.GastrointestinalNo N/V/D, No c/o abdominal tenderness. No c/o of food intolerances. EarsPt denies decreased hearing, ear pain or increased cerumen production/drainage.