SOAP NOTE
Name: MB Date: 4/9/19 Time: 1:30 pm
Age: 41 Sex: F
SUBJECTIVE
CC:
“I’ve been having pain in my lower back and I’ve been peeing a lot for about a week.”
HPI:
41-year-old female G2P2A0 presents to clinic c/o "pain in lower back pain and peeing a lot for about a
week". She states achy pain and discomfort in the lower back area, 4-5/10 in intensity. She states she has
been urinating much more frequently than usual and admits to some slight burning with urination. Denies
any fever or urinary incontinence. Her urine appears cloudy and has a foul odor. Minimal tenderness to
lower mid-abdomen when palpated. CVA negative. Pt has been treating pain with ibuprofen with minimal
relief. Pt has history of UTI’s and depression.
Medications:
Ibuprofen 200 mg 1-2 tabs PO q 6 hours prn pain
Wellbutrin 150 mg PO daily for depression
PMH
Allergies:
NKA
Medication Intolerances:
None listed
Chronic Illnesses/Major traumas
Depression – F32.9
Hospitalizations/Surgeries
Hospitalized x 2 for vaginal deliveries
No surgical history
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:44:01 GMT -05:00
https://www.coursehero.com/file/48563677/NSG-6430-Week-3-SOAPdoc/
Name: MB Date: 4/9/19 Time: 1:30 pm
Age: 41 Sex: F
SUBJECTIVE
CC:
“I’ve been having pain in my lower back and I’ve been peeing a lot for about a week.”
HPI:
41-year-old female G2P2A0 presents to clinic c/o "pain in lower back pain and peeing a lot for about a
week". She states achy pain and discomfort in the lower back area, 4-5/10 in intensity. She states she has
been urinating much more frequently than usual and admits to some slight burning with urination. Denies
any fever or urinary incontinence. Her urine appears cloudy and has a foul odor. Minimal tenderness to
lower mid-abdomen when palpated. CVA negative. Pt has been treating pain with ibuprofen with minimal
relief. Pt has history of UTI’s and depression.
Medications:
Ibuprofen 200 mg 1-2 tabs PO q 6 hours prn pain
Wellbutrin 150 mg PO daily for depression
PMH
Allergies:
NKA
Medication Intolerances:
None listed
Chronic Illnesses/Major traumas
Depression – F32.9
Hospitalizations/Surgeries
Hospitalized x 2 for vaginal deliveries
No surgical history
This study source was downloaded by 100000851720696 from CourseHero.com on 06-21-2024 18:44:01 GMT -05:00
https://www.coursehero.com/file/48563677/NSG-6430-Week-3-SOAPdoc/
