HERZING UNIVERSITY NU631 UNIT 10 SOAP NOTES 2024
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Malodorous urine and discharge
HPI: History of Present Illness (HPI)
The patient presents to the women's health clinic with a chief complaint of
malodorous urine and discharge. She reports that the symptoms began
approximately one week ago. The discharge is described as thin, frothy,
and yellow green in color. The patient also notes an accompanying strong,
unpleasant odor. There is no associated pain or burning with urination, but
she reports mild itching and irritation in the vaginal area.
The patient has a significant history of recurrent urinary tract infections
(UTIs) and has been previously educated on proper hygiene and cleaning
techniques to prevent UTIs. Despite adherence to these preventative
measures, she continues to experience frequent episodes of urinary and
vaginal symptoms.
Given the nature of her discharge and the presence of malodorous urine,
the provider is suspicious of trichomoniasis (Trichomonas vaginalis
infection). The patient denies any recent changes in sexual partners and
reports consistent use of barrier protection during sexual activity. She has
not experienced any fever, chills, or systemic symptoms.
The patient’s medical history is otherwise unremarkable, with no known
allergies, chronic conditions, or current medications that could contribute
to her symptoms.
PMH: Past Medical History (PMH)
-Recurrent Urinary Tract Infections (UTIs): Extensive history of frequent
UTIs. Patient has been educated on proper hygiene and cleaning
techniques to prevent UTIs.
-Allergies: No known drug allergies.
-Chronic Conditions: None reported.
-Medications:
- NuvaRing (vaginal contraceptive ring)
,HERZING UNIVERSITY NU631 UNIT 10 SOAP NOTES 2024
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
-Surgical History: No previous surgeries.
-Other: No known chronic illnesses or conditions.
ALLERGIES NKDA
MEDICATIONS Medications
-NuvaRing: Vaginal contraceptive ring for birth control.
-MiraLAX: Occasionally for constipation.
SH Social History
-Living Situation: Lives with her boyfriend.
-Employment: Works at a local bar.
-Education: Attends school full-time at the University of Tampa, majoring
in an unspecified field.
-Diet: Follows a strict and healthy diet.
-Support System: Primarily relies on her close friends and boyfriend for
support. Has one brother and one sister, though she is less dependent on
them for daily support.
- Faith: Not actively practicing any faith or religion.
-Allergies: Allergic to pet dander.
-Sexual History Stable sexual partner, consistent use of barrier protection,
no recent changes in sexual partners.
-Exercise: Plays college volleyball, maintaining an active lifestyle.
-Substance Use: No history of smoking, alcohol, or drug abuse.
FH Family History
-Father: History of hypertension and myocardial infarction at age 50.
-Mother: History of breast cancer, currently in remission, and
osteoporosis.
-Brother: Healthy, no known medical conditions.
-Sister: History of asthma, well-controlled with medication.
- Maternal Grandmother: History of type 2 diabetes and congestive heart
failure.
-Maternal Grandfather: History of chronic obstructive pulmonary disease
(COPD) due to a long history of smoking.
-Paternal Grandmother: History of rheumatoid arthritis and stroke at age
70 with partial recovery.
-Paternal Grandfather: History of prostate cancer, currently in remission,
and hypertension.
, HERZING UNIVERSITY NU631 UNIT 10 SOAP NOTES 2024
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
HEALTH Health Promotion and Maintenance
PROMOTION &
MAINTENANC Nutrition:
E - Continue following a strict and healthy diet.
- Ensure adequate hydration, aiming for at least 8 cups of water daily.
- Incorporate a balanced intake of fruits, vegetables, whole grains, lean
proteins, and healthy fats.
- Limit intake of processed foods, high-fat foods, and sugary beverages.
Physical Activity:
- Maintain an active lifestyle by continuing participation in college
volleyball.
- Incorporate additional forms of physical activity such as strength
training, flexibility exercises, and cardiovascular workouts.
- Aim for at least 150 minutes of moderate-intensity aerobic activity or 75
minutes of vigorous-intensity aerobic activity per week, along with
muscle-strengthening activities on 2 or more days a week.
Preventive Health:
- Schedule regular check-ups with a primary care provider for routine
health screenings.
- Ensure up-to-date immunizations, including annual influenza
vaccination and other age-appropriate vaccines.
- Perform regular self-breast exams and schedule clinical breast exams as
recommended.
Sexual Health:
- Continue consistent use of barrier protection during sexual activity
to prevent sexually transmitted infections (STIs).
- Consider regular STI screenings as recommended by a healthcare
provider.
- Discuss with a healthcare provider the continuation and effectiveness of
the NuvaRing for contraception.
Mental Health:
- Maintain a strong support system with close friends and boyfriend.
- Consider mindfulness practices such as meditation, yoga, or
journaling to manage stress.
- Seek professional help if experiencing symptoms of anxiety, depression,
or other mental health concerns.
Allergy Management:
- Continue taking Zyrtec (Cetirizine) 5 mg once daily for allergies.
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Malodorous urine and discharge
HPI: History of Present Illness (HPI)
The patient presents to the women's health clinic with a chief complaint of
malodorous urine and discharge. She reports that the symptoms began
approximately one week ago. The discharge is described as thin, frothy,
and yellow green in color. The patient also notes an accompanying strong,
unpleasant odor. There is no associated pain or burning with urination, but
she reports mild itching and irritation in the vaginal area.
The patient has a significant history of recurrent urinary tract infections
(UTIs) and has been previously educated on proper hygiene and cleaning
techniques to prevent UTIs. Despite adherence to these preventative
measures, she continues to experience frequent episodes of urinary and
vaginal symptoms.
Given the nature of her discharge and the presence of malodorous urine,
the provider is suspicious of trichomoniasis (Trichomonas vaginalis
infection). The patient denies any recent changes in sexual partners and
reports consistent use of barrier protection during sexual activity. She has
not experienced any fever, chills, or systemic symptoms.
The patient’s medical history is otherwise unremarkable, with no known
allergies, chronic conditions, or current medications that could contribute
to her symptoms.
PMH: Past Medical History (PMH)
-Recurrent Urinary Tract Infections (UTIs): Extensive history of frequent
UTIs. Patient has been educated on proper hygiene and cleaning
techniques to prevent UTIs.
-Allergies: No known drug allergies.
-Chronic Conditions: None reported.
-Medications:
- NuvaRing (vaginal contraceptive ring)
,HERZING UNIVERSITY NU631 UNIT 10 SOAP NOTES 2024
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
-Surgical History: No previous surgeries.
-Other: No known chronic illnesses or conditions.
ALLERGIES NKDA
MEDICATIONS Medications
-NuvaRing: Vaginal contraceptive ring for birth control.
-MiraLAX: Occasionally for constipation.
SH Social History
-Living Situation: Lives with her boyfriend.
-Employment: Works at a local bar.
-Education: Attends school full-time at the University of Tampa, majoring
in an unspecified field.
-Diet: Follows a strict and healthy diet.
-Support System: Primarily relies on her close friends and boyfriend for
support. Has one brother and one sister, though she is less dependent on
them for daily support.
- Faith: Not actively practicing any faith or religion.
-Allergies: Allergic to pet dander.
-Sexual History Stable sexual partner, consistent use of barrier protection,
no recent changes in sexual partners.
-Exercise: Plays college volleyball, maintaining an active lifestyle.
-Substance Use: No history of smoking, alcohol, or drug abuse.
FH Family History
-Father: History of hypertension and myocardial infarction at age 50.
-Mother: History of breast cancer, currently in remission, and
osteoporosis.
-Brother: Healthy, no known medical conditions.
-Sister: History of asthma, well-controlled with medication.
- Maternal Grandmother: History of type 2 diabetes and congestive heart
failure.
-Maternal Grandfather: History of chronic obstructive pulmonary disease
(COPD) due to a long history of smoking.
-Paternal Grandmother: History of rheumatoid arthritis and stroke at age
70 with partial recovery.
-Paternal Grandfather: History of prostate cancer, currently in remission,
and hypertension.
, HERZING UNIVERSITY NU631 UNIT 10 SOAP NOTES 2024
SOAP Note 1 Name: Russ Eddins
Typhon Encounter#: 4550-20240715-
NU_631 : 002
Herzing University Comprehensive: Focused:
HEALTH Health Promotion and Maintenance
PROMOTION &
MAINTENANC Nutrition:
E - Continue following a strict and healthy diet.
- Ensure adequate hydration, aiming for at least 8 cups of water daily.
- Incorporate a balanced intake of fruits, vegetables, whole grains, lean
proteins, and healthy fats.
- Limit intake of processed foods, high-fat foods, and sugary beverages.
Physical Activity:
- Maintain an active lifestyle by continuing participation in college
volleyball.
- Incorporate additional forms of physical activity such as strength
training, flexibility exercises, and cardiovascular workouts.
- Aim for at least 150 minutes of moderate-intensity aerobic activity or 75
minutes of vigorous-intensity aerobic activity per week, along with
muscle-strengthening activities on 2 or more days a week.
Preventive Health:
- Schedule regular check-ups with a primary care provider for routine
health screenings.
- Ensure up-to-date immunizations, including annual influenza
vaccination and other age-appropriate vaccines.
- Perform regular self-breast exams and schedule clinical breast exams as
recommended.
Sexual Health:
- Continue consistent use of barrier protection during sexual activity
to prevent sexually transmitted infections (STIs).
- Consider regular STI screenings as recommended by a healthcare
provider.
- Discuss with a healthcare provider the continuation and effectiveness of
the NuvaRing for contraception.
Mental Health:
- Maintain a strong support system with close friends and boyfriend.
- Consider mindfulness practices such as meditation, yoga, or
journaling to manage stress.
- Seek professional help if experiencing symptoms of anxiety, depression,
or other mental health concerns.
Allergy Management:
- Continue taking Zyrtec (Cetirizine) 5 mg once daily for allergies.
