Comprehensive Soap note.
Remember that this is a mock patient. You will make up the history and exam findings as if you have interviewed this patient and performed an exam. You are required to use a SOAP note template with citations and references in APA format. You will include three ddx with supportive documentation, citations, and references! Please be aware Turn it in similarity should be less than 20%
If the information was not provided in the case study, be creative and ask yourself what would be important for me to ask this patient if he were in my office. All systems should be included in the ROS and for the Physical Exam
Use the following case to complete a focused SOAP note:
UTI (N39.0)
A 27-year-old female came to the office complaining of dysuria, nocturia, and hypogastric abdominal pain. Pt denies fever or CVT. Denies pass medical history. College student doing her master, still living at the parents’ house. Denies tobacco, alcohol or illicit drugs use included marijuana. In stable relationship with his partner for last 4 years. She reports sexual activities using condom for protection.
Family history: modern alive with HTN, father and sister healthy.
Medications: Macrobid 100 mg twice a day PO for 10 days.
Labs: Urine dipstick shows high concentration of nitrites and leukocytes. Urinalysis and urine culture is requested.
Procedures:
Pt education: Pt is advised to drink plenty of water, to not eat heat or spicy food, and to clean the urethral external part with light soap and water. Pt was advised to abstain from sexual activity for the next week. She was advised that the urine can turn yellow when she is taking the medication.
Referrals: n/a
Follow-up: return to the office 4 weeks or earlier if the problems worsen.Urinalysis with culture two weeks after finishing the antibiotic.
At the end of the visit, the patient understands the diagnosis, medications’ benefits, and adverse effects. The patient agrees to continue the present treatment, and if the patient does not feel better should visit the nearby emergency room.
On the exam, his vital signs are BP 110/70; P 64; R 14; T 98.2; Pulse ox: 98%.
