NURS 623 SOAP Note Adult 1 Topic
UTI.
S.O.A.P. Note
A 36-year-old female presents with twenty-four-hour history of urinary frequency and burning
with urination. She is recently divorced.
Chief Complaint
Frequency and urgency with urination for the last 24 hours.
History of Present Illness
A 36-year-old female presents to the clinic with frequency and burning with urination. She
reports this started roughly 24 hours ago. Patient reports the pain with urination is a 3 out of 10.
She has not tried taking anything for the pain or frequency. She reports that she is recently
divorced and has no new sexual partners. Patient reports that she has not had a urinary tract
infection in years.
Past Medical History
Past Medical history: None
Past surgical history: ACL reconstruction in 2010
Patient is current in her immunizations
No Medication or seasonal allergies
Current medications: None
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Asthma, hypertension and type 2 diabetes
Father: Hypertension
Brother: Unknown
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient has a Bachelors degree in Engineering and works full time at Hill Air Force Base, is a
divorced heterosexual. Pt denies any alcohol or illicit drug use. She does not smoke or use
chewing tobacco. Pt does moderate exercise 3 times a week and is on a regular diet.
UTI.
S.O.A.P. Note
A 36-year-old female presents with twenty-four-hour history of urinary frequency and burning
with urination. She is recently divorced.
Chief Complaint
Frequency and urgency with urination for the last 24 hours.
History of Present Illness
A 36-year-old female presents to the clinic with frequency and burning with urination. She
reports this started roughly 24 hours ago. Patient reports the pain with urination is a 3 out of 10.
She has not tried taking anything for the pain or frequency. She reports that she is recently
divorced and has no new sexual partners. Patient reports that she has not had a urinary tract
infection in years.
Past Medical History
Past Medical history: None
Past surgical history: ACL reconstruction in 2010
Patient is current in her immunizations
No Medication or seasonal allergies
Current medications: None
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Asthma, hypertension and type 2 diabetes
Father: Hypertension
Brother: Unknown
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient has a Bachelors degree in Engineering and works full time at Hill Air Force Base, is a
divorced heterosexual. Pt denies any alcohol or illicit drug use. She does not smoke or use
chewing tobacco. Pt does moderate exercise 3 times a week and is on a regular diet.
