10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health

Search   

Download
14K views 12  1
Now 2 of 5RELATED TITLES  Search document 
Soap Note 4 (CPII)
Uploaded by Flor Otero on Mar 07, 2016 
soap Full description

   
Save Embed Share Print Sample Soap Obgyn Soap Note Soap Note
Example

Download Now 2 of 5  Search document 

 

Soap Note
Date: 06/25/2014, 27 Years old

Chief Complaint (CC):   “burning and pain with urination”

History o present !llness "H#!$% &' (' presents with unusually re)uent urination, strong urge to
urinate, and pain, dis*o+ort, and burning sensation during urination sin*e last three days' (ates
that she oided - ti+es in 1'5 hours at .ost*o yesterday' Her urine loos *loudy and has a oul
odor' enies eer,nausea, o+iting, +yalgia, lan pain, blood in urine, any aginal dis*harge,
and, aginal/ular irritation' !s seually a*tie, has sa+e partner or last 4 years'

 Past Medical History (PMH):

.hildhood% .roup "10$' 3o *hroni* illness or *onditions

dult !llness% 3o +aor health proble+s e*ept +inor *old and eer'

/8Y3% 191909091, with nor+al aginal deliery' ne liing *hild' :enar*he age 1-';ast
+enses 01/02/2014' .urrently, seually a*tie' !s +arried and has sa+e partner or 4 year' ;ast
8Y3 appoint+ent in 0/22/201-' <as tested or (=s in the 8Y3 oi*e' <as negatie or
.hla+ydia, H!>, and 8onorrhea'

(urgeries% 3one

#sy*hiatri*% 3one'

Medications: !s not taing any pres*ription, oer9the9*ounter drugs, or ita+ins or +ineral

supple+ents' 
This document is...
Allergies % 3o nown allergies' 3o seasonal allergy'
 Useful  Not useful
 Immuniation % .o+pleted - doses o H#> a**ine in 200-, re*ent =9dap in 2011 "postpartu+$,
Related lu
titles


shot in 10/201-' ll *hildhood i++uni?ations are up to date' 3eer had any rea*tions to
a**ines in the past
https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 1/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health
a**ines in the past'

!amily history: Search   

@ather% alie A H o : 2

Download Now
:other% de*eased9 H o H=3
2 of 5  Search document  
(ister B 1% alie 9 H=3

(on % lie 

Sample Soap Obgyn Soap Note

"e#ie$ of System: Soap Note pediatric soap geriatric soap SOAP
Example note 3 note Diabe

8eneral' 3o generali?ed weaness or atigue or re*ent *hanges in the weight'

Cespiratory% 3o *ough, shortness o breathing' 3o history o sth+a or seasonal allergy'

.ardioas*ular% 3o *ough, dyspnea on eertion, orthopnea, ede+a, and unusual atigue' 3o

history o heart +ur+urs'  3o history o hypertension, rheu+ati* eer, and high

*holesterol'

8astrointestinal% */o o +ild pain in the suprapubi* area' enies nausea , o+iting, and

abdo+inal pain'
8D% ./o o urinary re)uen*y, urgen*y and dysuria sin*e past three days' (tates that she had to
urinate at least - ti+es in 1'5 hours at .ost*o yesterday' enies any aginal dis*harge, and
aginal/ular irritation' (tates that she neer had urinary tra*t ine*tion beore' !s seually
a*tie'

%&'ecti#e:

ppearan*e% &'(' is a *ooperatie, alert, +aintains eye *onta*t, loos her stated age, well
groo+ed and appropriately dressed or the weather and the settings' 3o respiratory distress'
ppropriate ae*t'

ital Signs: #% 112/75, HC% 72, C% 16, =% E'E,

Height% 6- in*hes <eight% 120 lb' :!% 21'-

=hora and lungs% reath sounds are *lear and nor+al' 3o adentious breath sounds'

.ardioas*ular% 3o +ur+ur, gallops, rubs or etra heart sounds' 3o thrills, heaes or lits' (1, (2
 present'

8astrointestinal% bdo+en sot and non9tender to tou*h, positie bowel sounds present'

8D% (uprapubi* area tender to tou*h, 3o .> tenderness'


a&: This document is...
1' ipsti* urinalysis9 positie or nitrite and leuo*yte esterase positie  Useful  Not useful
Related 2'titles


Drine .ulture

https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 2/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health
Impression*Planning:

Search
Diagnosis:  Drinary tra*t 
ine*tion, site not spe*iied "!.  A 5'0$  

Download Now 2 of 5  Search document  

 
Sample Soap Obgyn Soap Note Soap Note pediatric soap geriatric soap SOAP
Example note 3 note Diabe

Differential Diagnosis: aginitis"!.9 A 616'10$, pyelonephritis "!.9 *ode 50'E0$,

oera*tie bladder "!.  A 56'51$'

=he diagnosis o urinary tra*t ine*tion was +ade based on the patientFs *hie *o+plain, history
o present illness, dipsti* urinalysis result, as well as, physi*al ea+ination' .lini*al indi*ators
su*h as presen*e o suprapubi* tenderness, dysuria, re)uen*y, and urgen*y used to predi*t the
diagnosis o urinary tra*t ine*tion "#atel, ;ee, G 8old+an, 201-$' =he diagnosis o aginitis
was ruled out due to positie urine dipsti* test, absen*e o sy+pto+s su*h as aginal dis*harge
and aginal/ular irritation " #atel et al', 201-$' (i+ilarly, the diagnosis o pyelonephritis was
ruled out be*ause patient did not hae sy+pto+s su*h as eer, nausea, o+iting, +yalgia, and
lan pain whi*h is +ore *onsistent with the diagnosis o pyelonephritis "o+ino, 2014$' en
though, sy+pto+s su*h as urgen*y and re)uen*y are *onsistent with the diagnosis o oera*tie
 bladder, the positie result o dipsti* urinalysis helped to rule out the diagnosis o oera*tie
 bladder "#atel et al', 201-$'

#lan% "**ording #atel et al', 201-I !ntelihealth, 2014 $

1' #res*ribe her a*tri+ ( # J12 hours or - days'

2' du*ate her to aoid sper+i*idal produ*ts be*ause they de*rease aginal la*toba*illi and

in*rease the ris o D=!'

-' dise her to drin seeral glasses o water ea*h day' @luids dis*ourage the growth o ba*teria
 by lushing out your urinary tra*t' rining *ranberry ui*e +ay deter ba*terial growth by
de*reasing the ability o ba*teria to sti* to the urethra'

4' dise her to wipe ro+ ront to ba* to preent the spread o intestinal ba*teria ro+ the
re*tu+ to the urinary tra*t' du*ate her that wo+en always should wipe toilet tissue ro+ ront
to the ba* ater haing a bowel +oe+ent'

5' du*ate her that seual a*tiity is one o the strongest ris a*tors or D=!' =hereore, to
de*rease the spread o ba*teria during se, adise her to urinate ater seual inter*ourse to lush
 ba*teria ro+ your urethra'

6' du*ate patient to *o+plete ull - days *ourse o antibioti*'

Health :aintenan*e%

1' di*e patient to tae 400 +*g oli* supple+ent daily' @urther+ore, edu*ate her that oli* a*id

is ery i+portant or wo+en o *hild bearing age to preent birth dee*t een when she is not
 planning or any pregnan*y' !tFs needed during the irst ew wees o pregnan*y, oten beore a

wo+an nows sheFs pregnant "HH(, 2014$' This document is...
 Useful  Not useful
Related titles


https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 3/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health

Search   

2 Search document
 

Download Now of 5   

2' (*reening or *eri*al *an*er% du*ate patient that she should get her pap test eery - years to
Sample Soap Obgyn Soap Note Soap Note pediatric soap geriatric soap SOAP
s*reen or *eri*al *an*er' Her last pap test was in 0/201-, nor+al, so adise her to s*hedule her 
Example note 3 note Diabe
net pap test in 0/ 2016'

-' n*ourage her to get well9wo+en isit on*e a year and her blood pressure *he*ed at least one
eery 2 years "HH(, 2014$

4' du*ate her about the i+portan*e o lu shot and its side ee*t and adise her to get it eery
year to preent lu'

5' du*ate patient to go or dental isit twi*e a year or eery 6 +onths ">ori*, 2012$'

6' dise patient to get tested or H!> at least on*e'

7' du*ate her that based on her a+ily history or heart disease and her ris or heart disease
"diabetes, s+oing, high blood pressure, and obesity$ she +ight need to get her blood *holesterol
*he*ed on*e eery 5 years "HH(, 2014$'

E' =ea*h patient to get her eye ea+ined eery two years ">ori*, 2012$'


This document is...
 Useful  Not useful
Related titles


https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 4/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health

Search   

Download Now 2 of 5  Search document  

Ceeren*es
o+ino, @'&' "2014$' =he 59:inute *lini*al *onsult "22nd ed'$' #hiladelphia, #%
Sample Soap Obgyn<illia+s
;ippin*ott Soap Note Soap Note
G <ilins' pediatric soap geriatric soap SOAP
Example note 3 note Diabe
!ntelihealth' "2014$' urinary tra*t ine*tions in wo+en' Cetrieed ro+

  http%//www'intelihealth'*o+/arti*le/urinary9tra*t9ine*tion9in9wo+en

#atel, '3, ;ee,'D'&', G 8old+an,H'' "201-$' Drinary tra*t ine*tions in wo+en' Cetrieed

ro+ htps%//online'epo*rates'*o+/no@ra+e/show#age'doK+ethodLdiseases

G:onograph!dL77G*tie(e*tion!dL11

D'(' depart+ent o health G hu+an seri*es "HH($' "2014$' Healthinder'go' retrieed ro+
  http%//healthinder'go/+yhealthinder/Cesult'aspK
ageL-0GgenderLe+aleGpregnantL 

alse

>ori*, ;'&' "2012$' Health s*reening 9 wo+en 9 age 1E A -' Cetrieed ro+

http%//www'nl+'nih'go/+edlineplus/en*y/arti*le/007462'ht+

Reward Your Curiosity 

This document is...
Everything you want to read.
 Useful  Not useful
Anytime. Anywhere. Any device.
Related titles


https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 5/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health

Read Free For 30 Days

Search   

Cancel Anytime
Download Now 2 of 5  Search document  

Share
Sample this
Soap document
Obgyn Soap Note Soap Note pediatric soap geriatric soap SOAP
Example note 3 note Diabe
    

Related Interests
Urinary Tract Infection Public Health Medical Specialties Clinical Medicine Diseas

Related Searches
Obgyn Soap Hypertension Soap Note Soap Note

Documents Similar To Soap Note 4 (CPII)

Sample Soap Obgyn Soap Note Soap Note pediatric soap note geriatric so
UPLOADED BY Example UPLOADED BY 3 UPLOADED
Douglas Greg … UPLOADED BY Sandhya Rubens UPLOADED BY api-282
Bluerobins api-282129457

More From Flor Otero


This document is...
 Useful  Not useful
Related titles 


https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 6/7
10/16/2019 Soap Note 4 (CPII) | Urinary Tract Infection | Public Health

Search   

Male Nurses Xylitol Nasal Migraine Depth Detail Simon The

Irrigation in the… Houser
UPLOADED BY
Download Now
Flor Otero UPLOADED BY 2UPLOADED BY
of 5Otero
Flor UPLOADEDBY Search document
UPLOADED
 
Flor Ote
Flor Otero Flor Otero

Sample Soap Obgyn Soap Note Soap Note pediatric soap geriatric soap SOAP
Example note 3 note Diabe
ABOUT SUPPORT

About Scribd Help / FAQ

Press Accessibility

Our blog Purchase help

Join our team! AdChoices

Contact Us Publishers

Invite Friends

Gi s

LEGAL
   
Terms

Privacy

Copyright

Copyright © 2019 Scribd Inc. . Browse Books . Site Directory . Site Language: English


This document is...
 Useful  Not useful
Related titles


https://www.scribd.com/doc/302854178/Soap-Note-4-CPII 7/7