NRNP 6552 Focused SOAP Note for Urinary Tract Infection (DETAILED SOLUTIONS).

NRNP 6552 Focused SOAP Note for Urinary Tract Infection (DETAILED SOLUTIONS). Patient Information: D.S, 42, Female, Hispanic S. CC (chief complaint): "I feel a burning sensation when urinating for the past one week." HPI: D.S is a 42-year-old Hispanic American female presenting to our emergency department with augmented pain and burning while urinating and a fever that only subsides when she takes acetaminophen but keeps returning as soon as it wears off after approximately 3 hours. For the past week, the patient has reported an increased urgency to urinate. Though, her urine output is less cloudy. The pain is rated 8 out of 10 on the severity scale. Current Medications: None Allergies: No Known Food, Drug, or medication allergies PMHx: Influenza vaccine administered on September 18, 2019, Tdap in 2018, and Hepatitis B on June 15, 2017. The patient reports no significant surgeries or illnesses in the past. Soc & Substance Hx: The patient report being sexually active with one sexual partner. She is an accountant by profession and lives with her partner and two children in California. The patient reports drinking one glass of wine daily and smoking at least one cigar pack daily. However, she refutes using recreational drugs such as cocaine, heroin, or marijuana. Regarding her smoking habit, the patient has a functional smoke detector in her house that helps detect fires in her home. The patient denies drinking or texting while driving to ensure her safety, and she also ensures that she puts on her safety belt before driving. The patient reports having a solid support system that comprises her spouse, children, parents, and friends. Fam Hx: The patient's mother is alive with history of COPD and diabetes meaning the patient may have diabetes. However, his father succumbed a few years ago to a car accident. The patient has three siblings with no history of chronic illness. Her two children are also in good health and have no record of chronic illness Surgical Hx: The patient reports no surgical procedures conducted in the past. Mental Hx: The patient denies a history of depression, anxiety, or any mental disorder. The patient also denies suicidal thoughts or engaging in practices that may result in self-harm. Violence Hx: The patient denies experiencing any form of violence from her family members, friends, or spouse. NRNP 6552: Advanced Nurse Practice in Reproductive Health Care © 2022 Walden University, LLC Reproductive Hx: The patient reports an irregular menstrual cycle, and two months have passed since her last menstrual period. Her previous clinical breast and pap smear exam was on April 16, 2022, and the results indicated that they were normal. The patient reports using IUD as her contraceptive method and only participates in vaginal intercourse with her male partner. ROS: GENERAL: The patient reports no weight loss or gain. However, the patient reports experiencing weakness, chills, and fever. HEENT: Head: The patient reports no headaches or injuries in the head. The patient also denies tinnitus or vertigo, or hearing problems. The patient denies a runny nose, congestion, or sneezing. The patient reports having her dental examination three months ago. Thus, she denies gingivitis, ulceration lesions, or bleeding gums. The patient denies sore throat or swallowing problems SKIN: The patient denies skin cracking, itching, moles, or color changes. The patient also denies skin lesions. CARDIOVASCULAR: The patient denies experiencing chest pains, discomfort, or pressure in her chest. The patient also denies edema or SOB palpitations. RESPIRATORY: The patient denies breathlessness, sputum, or coughing blood. The patient also denies dyspnea while resting. GASTROINTESTINAL: The patient complains of pain in the lower abdominal area, vomiting, nausea, or changes in bowel movements. The patient reports having a good appetite. NEUROLOGICAL: the patient refutes loss of memory, numbness, seizures, headaches, paralysis, or syncope.