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Week 3 Soap Note Family

Week 3 Soap Note Family

Week 3 Soap Note Family

Using this template, complete one SOAP note from a patient in your current NSG6440 clinical experience. The completed note should be submitted to the Submissions Area.


Name: LH

Date: 07/31/2020

Time: 9:45AM


Age: 31

Sex: Female



“It hurts when I pee, and my lower stomach area hurts”


This is a well-established patient at the clinic. The patient states that she has pain on urination and a pain in her lower abdomen. The lower abdomen pain is present at all times of day and night. It is located in the lower abdomen near the groin area. The painful urination is only present when she urinates. These symptoms began around 4 days ago. The painful urination is described as burning sensation. The lower abdominal pain is described as a dull pain 5/10. It can radiate to her lower back at times. The patient has been using Tylenol to alleviate the pain, but it does not full go away. She also describes having to go to the bathroom frequently but with a small amount of urine. Urine color is normal.

Medications: (list with reason for med)

Tylenol 500mg 1 tab every 8 hours as needed (for abdominal pain)


Allergies: NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None, G0P0

Family History

Mother: Alive, 61, Hypertension, Type 2 Diabetes

Father: Alive, 62, Hypertension, Osteoarthritis

Siblings: Sister, Alive, 28, No current health issues

Grandparents: Deceased in Cuba, unknown medical issues

Children: None

Social History

General: Born in Miami to Cuban Immigrants.

Marital status: Single, no children, no partners

Living situation: Living alone in an apartment in Miami, needs are well taken care of due to high paying job, parents live 20 minutes away in a house. Friends live close to her.

Children: None

Occupation: Works as a financial advisor in downtown Miami.

Leisure Patterns: Patient states that she goes out to drink with her friends at least once a week at local bars and clubs. Sexually active with multiple partners in a month.

Social habits: Drinks at least once a week, a few cocktails. Denies smoking or illegal drug use. Is sexually active with multiple partners.

Spirituality: No religious beliefs

Nutrition: Patient states that she follows a healthy diet and watches her weight closely.

Sleep Patterns: Patient reports sleeping 7 to 8 hours daily.



Denies weakness, fatigue, or fever.

Head: Denies headache, head injury, dizziness, or lightheadedness.










Reports abdominal pain in the lower abdominal area 5/10. Denies trouble swallowing, heartburn, changes in appetite, or nausea. Denies stool changes Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis.




Goes to the bathroom 9-10 times a day. Reports nocturia, urgency, and burning pain during urination. Denies polyuria. Denies hematuria, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence.

Menarche at age 12. LMP: 7/13/2020. Flow is normal. Period lasts 4 days. Denies bleeding between periods. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G0P0. Uses condoms as birth control method. Sexually active at the moment. Has several partners in a one-month period. Denies STD’s.



Neck: Non-contributory


Denies muscle weakness, paresthesia, loss of sensations. Denies muscle or joint pain, stiffness. Denies fever, chills, rash, anorexia, weight loss or weakness.


Denies lumps, pain, discomfort or nipple discharge.




Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.

Peripheral Vascular: Non-contributory


Denies nervousness, tension, mood changes, depression, or memory changes.


Weight 150lbs BMI 21.5

Temp 98.4 F

BP 115/78

Height 70”

Pulse 76

Resp 17

General Appearance

Patient is alert and oriented x 4. Speaks clearly. Good personal hygiene.






S1, S2. Regular rate and rhythm. No murmurs, no gallops. No edema.


Lungs are clear to auscultation bilaterally, good respiratory effort. No rales, rhonchi or wheezing.


Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.




Suprapubic pain on palpation. No CVA tenderness. External genitalia with good pubic hair distribution. No vulvar lesions or masses noted.

Bimanual examination: Mobile cervix that is not painful. Adnexal tenderness present. Vaginal walls are smooth and pink with no lesions noted. Ovaries are non-palpable. No uterine masses.






Alert relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.

Lab Tests

Urine Dipstick- presence of leukocyte esterase, and nitrites

Urinalysis w/ Culture – pending

STD tests (Chlamydia, Gonorrhea, HIV) – pending


Special Tests

Pap Smear conducted – Pending



1. Acute cystitis without hematuria (N30.00).

Patient has classical symptoms associated with a lower urinary tract infection. These include pain on urination, pain in the pelvic area, burning urination, and frequent urination. The urine dipstick came back positive for leukocyte esterase and nitrites which are signs of acute cystitis (Gupta, Grigoryan, & Trautner, 2017). Additionally, the patient is at increased risk due to new sexual partners monthly.


1. Chlamydial cystitis and urethritis (A56.01): Patient’s symptoms may also be characteristic of a chlamydial STD infection. Chlamydia symptoms include painful urination and adnexal tenderness which was found in the bimanual examination (STD Facts – Chlamydia, n.d.). The patient states she uses condoms, which reduces the likelihood of this diagnosis.

2. Gonococcal cystitis and urethritis, unspecified (A54.01): Burning urination and adnexal tenderness are also symptoms of gonorrhea (STD Facts – Gonorrhea, n.d.). However, the patient states that she uses condoms which decreases the likelihood of this infection. We cannot confirm this diagnosis until the STD blood screening is complete.

3. Malignant neoplasm of bladder, unspecified (C67.9): Bladder cancer can cause symptoms associated with acute cystitis such as painful urination, bleeding on urination, frequent urination, and back pain. However, this patient does not have bleeding on urination, and blood was not found on the urine dipstick. Additionally, her family history shows that she is not at risk for cancer of the bladder. Painless hematuria is the most common sign of bladder cancer (DeGeorge, Holt, & Hodges, 2017).




Urinalysis w/culture – pending

Pap Smear- Pending

STD Screening- Pending

Therapeutic: Pharmacological:

Nitrofurantoin 100mg, 1 tab twice a day for 5 days.

Non-pharmacological/ Patient Education:

There is currently no evidence that non-pharmacologic therapies help to reduce symptoms in women with uncomplicated lower urinary tract infections (Gupta, Grigoryan, & Trautner, 2017). However, for this patients pain, a hot compress may help decrease the patients’s pain. Apply the hot compress to the affected pain area for 1 to 1.5 hours as needed to releive pain. Increasing fluid intake may help alleviate painful urination, and although cranberry juice has no known benefits at the moment, it may increase bladder function. Please complete the full antibiotic treatment even if symptoms begin to decrease before it is complete. Do not drink alcohol when taking antibiotic therapy. Refrain from any sexual practices until the full treatment is complete and a follow up is also complete with the PCP. Continue to eat a healthy diet. You may return to work as it is not a physically intense job. Conduct safe sexual practices such as washing before and after sex to prevent any further complications or recurrent infections. Keep just one sexual partner decrease the incidence of STDs. You may continue to take Tylenol to alleviate the pain if necessary.

Referral: None

Follow-Up: Follow-Up with PCP in one week to discuss results of the pending tests, as well as discuss any relieving or worsening of symptoms.

Evaluation of patient encounter:

I independently treated this patient with supervision from my preceptor. Preceptor involvement was only around 10% of this case.

Weaknesses: Patient was already well-established in the office, and it took me some time to establish rapport with her as I am not her usually healthcare professional.

Strengths: I accurately, and efficiently diagnosed this patient, and my provider praised me for excelling in a classic case of a urinary tract infection

Reflection: For common cases such as these, I feel like I am doing much better, as I have plenty of cases to practice with.


DeGeorge, K. C., Holt, H. R., & Hodges, S. C. (2017). Bladder Cancer: Diagnosis and Treatment. American Family Physician , 5017-514.

Gupta, K., Grigoryan, L., & Trautner, B. (2017). Urinary Tract Infection. Annals of Internal Medicine , 49-64.

STD Facts – Chlamydia. (n.d.). Retrieved April 11, 2020, from

STD Facts – Gonorrhea. (n.d.). Retrieved April 11, 2020, from

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