DUKE UNIVERSITY SCHOOL OF NURSING
Guide for SOAP Notes Documentation for an Acute Visit
Identifying information: L.B., female, 28 years old
Source and reliability: patient
Was an interpreter required? no
SUBJECTIVE:
Chief complaint: "I think I have a UTI."
HPI:
A 28-year-old White female presents to the office for an unscheduled visit with complaints of burning with urination, increased frequency, and urgency. She says she woke up on Friday morning, had to urinate, and experienced severe burning. The patient drank "a lot of water and took an Azo" after that but decided to come into the office today, two days later, after symptoms got worse. She says she took a yoga class this morning and had to urinate twice during the 1- hour class. L.B. thinks her urine looked "darker than usual" and is malodorous. Sometimes, she feels the urge to go but cannot produce any urine. Denies fever, chills, back, flank, abdominal, or pelvic pain, nausea, vomiting, hematuria, changes in vaginal discharge or odor, or painful intercourse.The patient states that she is monogamous, has regular intercourse with her boyfriend of 2 years, has no intention of getting pregnant, returns to the office every three months for her DepoProvera injection, has never had an STI nor is concerned about getting one. She had an uncomplicated medical abortion with Mifeprex at 6 weeks in 2019 when she was 24. While they frequently have sex, L.B. says they do not use any toys, lubrication, or spermicide and rely on DepoProvera as means of protection.
PMH: none
SH:
American, Irish heritage, spiritual. Works full-time from home as a Software Developer, lives with and is engaged to her fiancé, Brian. Uses DepoProvera for contraception with no intention of getting pregnant, no history of STIs, no children, no recent travel outside the country, daily caffeine intake, never smoked, drinks "two or three vodka sodas when I go out with friends every other weekend", no past or present drug use, eats "three meals a day, a lot of salads", drinks "close to 2 liters of water a day" and does yoga or Pilates 3-4x a week.
FMH:
Father – alive and well, hypertension Mother – alive and well Brother – autistic, high functioning Sister – alive and well Sister – alive and well 1 / 2
Accidents/Injuries: None
Hospitalizations/Surgical history: None
Allergies: NKA
Current Medications: Nature Made multivitamin with folic acid
LMP: 5/2021 - 1 year after starting Depo-Provera
Menstrual history: menstruation started at age 14 (2013)
OB history: G1P0A1
GYN history: last Pap 11/2020 with no abnormal findings
Immunizations : COVID (Moderna) x2, booster x1, Fluarix Quadrivalent x1 (2023), Heb B, MMR, Tdap UTD. No history of reactions to immunizations.Health Promotion/Maintenance : next Pap 11/2023, annual H&P 12/2023, dental 2/204, refused optometry referral (reports 20/20 vision, no glasses or contacts)
Review of Systems:
General: denies fever, chills, fatigue, weight change, and changes in appetite.
Skin: denies rashes, itching, changes in moles, dryness, flaking, and excessive sweating.Head and Neck: denies headaches, dizziness, changes in vision, hearing problems, sinus issues, sore throat, and swollen glands.
Respiratory: denies cough, shortness of breath, wheezing, and chest pain.
Cardiovascular: denies chest pain, palpitations, high blood pressure, swelling in the legs or ankles, and history of heart disease or murmurs.Gastrointestinal: denies stomach pain, nausea, changes in bowel habits, blood in stool, and heartburn.Genitourinary: changes in urination, burning, frequency, difficulty starting stream. Denies blood in urine, pain, or discomfort in the genital or urinary area, history of urinary tract infections, concerns about STIs, vulvar/vaginal irritation, vaginal discharge.
Musculoskeletal: denies joint pain, muscle pain, and limited range of motion.
Neurological: denies headaches, numbness, changes in coordination, seizures, and memory problems.Psychiatric: denies changes in mood, sleep disturbances, and concentration or memory problems.
OBJECTIVE:
Height: 5'6" (66 inches)
Weight: 120 lbs (54.4 kg)
BMI: 19.4
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