WOMEN’S HEALTH MINI SOAP NOTES

ICD 10: N39.0

S: Burning and pain with urination for 3 three days. Stated that her urine looks cloudy and has a foul odor. Denies fever, nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge, and, vaginal/vulvar irritation. She is sexually active, has same partner for last 4 years. G1P1001, with normal vaginal delivery. Menarche age 11. Last menses one week ago; regular 4- 5 days. Tested for STD one year ago. Negative for Chlamydia and Go...
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