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Posted: November 9th, 2022
Increased frequency and pain with urinatio
Write Assessment of SOAP
CC: Increased frequency and pain with urination
HPI:
T.S. is a 32-year-old girl who stories that for the previous two days, she has dysuria, frequency, and urgency. Has not tried something to Help with the discomfort. Has had this symptom years in the past. She is sexually energetic and has a brand new companion for the previous three months.
Medical Historical past:
None
Surgical Historical past:
Tonsillectomy in 2001
Appendectomy in 2020
Assessment of Methods:
Common: Denies weight change, constructive for sleeping problem as a result of e the flank pain. Feels heat.
Belly: Denies nausea and vomiting. No urge for food
Goal
VSS T = 37.three°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Examination:
gentle tenderness to palpation within the suprapubic space
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is famous.
The cervix seems regular.
Diagnostics: Urinalysis, STI testing, Papsmear
Assessment:
UTI
STI
Consider irregular findings on the genitalia and rectum
Apply ideas, theories, and ideas referring to well being Assessment strategies and diagnoses for the breasts, genitalia, prostate, and rectum
Assess well being situations primarily based on a head-to-toe bodily examination
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