More and More - Name N.A SOAP NOTE Date 18 March 2019 Age 56 Time 1400 Sex Female SUBJECTIVE CC Pt states \u201cher lower back hurts and she is having some

More and More - Name N.A SOAP NOTE Date 18 March 2019 Age...

This preview shows page 1 - 4 out of 7 pages.

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”.
Image of page 1
Family History Not Assessed
Image of page 2
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.
Image of page 3
Image of page 4

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture