SU_NSG6420_week6SOAP_king.m.docx - SOAP NOTE Name A.C Date Age 31 Time 1000 Sex F SUBJECTIVE CC \u201cI have burning when I pee I feel like I have to pee

SU_NSG6420_week6SOAP_king.m.docx - SOAP NOTE Name A.C Date...

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SOAP NOTE Name: A.C Date: 03/10/2020 Time: 1000 Age: 31 Sex: F SUBJECTIVE CC: “I have burning when I pee. I feel like I have to pee every few minutes” HPI: Pt presents today with c/o burning with urination, and lower abdominal pain. Pt. also states urgency and frequency. She states that when she does go, she only has trickles of urine; she denies change in color or odor. Pt. denies fevers, N/V/D. pt. states she does have a history of frequent UTIs. Pt. states that she usually gets a yeast infection after being treated for a UTI. Medications: (list with reason for med ) none PMH Allergies: none Medication Intolerances: - none Chronic Illnesses/Major traumas Urinary tract infections (every couple of months) Hospitalizations/Surgeries Child birth x 1 Family History
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Father – heart disease Mom – none Social History High school graduate, stay at home wife, married, 1 child, non-smoker, occasional alcohol use, denies drug use. ROS General no fever, chills, or night sweats Cardiovascular No CP or SOB Skin Clean, dry, and intact Respiratory
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