SOAP NOTE
Name:
N.A.
Date:
18 March 2019
Time:
1400
Age:
56
Sex:
Female
SUBJECTIVE
CC:
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 medications
OTC/Herbal
Ashwagandha
GABA
Melatonin
Calcium
PMH
Allergies
:
NKDA
Medication Intolerances
:
None
Chronic Illnesses:
None
Major Traumas:
None
Hospitalizations/Surgeries
Pregnancy (1992)
Pregnancy (1988)
Appendectomy (1987)
Other:
Immunizations:
Up to date.
Pt received influenza for this season, and recently
received TDaP.
Environmental Hazards:
Not assessed
Diet
: Drinks coffee and tea and states she “attempts to eat healthy”.
Family History
Not Assessed
Social History
Denies tobacco usage; denies ETOH; denies illicit drug usage.
Pt is not in a relationship and is not sexually active at this time.
Review of Systems
General
Pt denies fever, chills, decreased energy
levels
Cardiovascular
No c/o chest pain, palpitations, reported murmurs, or
edema.
Skin
No reports of flushing, rashes, excessive
dryness.
Respiratory
No reports of cough, shortness of breath, wheezing, or
dyspnea.
Eyes
Pt wears corrective lenses. Denies
excessive tearing, floaters, or other visual
disturbances.
Gastrointestinal
No N/V/D, No c/o abdominal tenderness. No c/o of
food intolerances.
Ears
Pt denies decreased hearing, ear pain or
increased cerumen production/drainage.
