SOAP Note to rewrite or bring turnitin to zero
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Week 3 SOAP Note- Sexually Transmitted Disease
United States University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxxxxxxx
SOAP Note- Sexually Transmitted Disease
SUBJECTIVE DATA:
Patient Name: C.K
Age: 41-years old,
Gender: Female,
Date of Birth: 03/15/1981
Chief Complain “I have had some pain and burning sensation, especially during urination. The urination has been accompanied by discharges that have been there for the last ten days.”
HPI: This is a 41-year old female patient who visits the facility with the complaints of experiencing lower abdominal pain and some burning sensation during urination. She reported that the problem started four days ago and has been experiencing occasional urges and urgency to urinate for the last three days. According to her, her visits to the toilet can be approximately ten times daily, and whenever she pees, she sees some brown discharge with a funky smell. The problem began after she had unprotected sex with her previous boyfriend. These problems have interfered with her work routine and messed up her focus while in the office where she is employed as an accountant. She reported to have used some painkillers to help in the reduction of the pain, but the pain never disappeared. She also admits that the pain worsens during urination, and it is neither sharp nor dull. She rates the pain as 8/10 and denies any factors that alleviates or relieves the pain. She reported being sexually active and has slept with more than one partner after the death of her husband. She has a regular menstrual cycle and had it a week ago and reported pain during intercourse. She denies fever, nausea, constipation, and vaginal bleeds.
Past medical history: She reported being diagnosed with sexually transmitted infections such as gonorrhea and chlamydia. She is also reported having had asthma disease.
Surgical: She admits to having undergone medical surgery during childhood and adulthood. At a young age, she had tooth removal, while in adulthood, she had a cesarean procedure.
LMP: her last menstrual cycle was on 28th December, 2021
Medications: She has been on Advil OTC as needed to manage her pain.
Allergies: she denies allergic reactions to food, drugs, and the environment in her adulthood. However, she admits experiencing some allergic reactions to dust and changes to the environment during her younger age.
Immunization: Her immunization is up to date, and she was recently vaccinated against flu and covid-19 on April last year.
Family History: The paternal father is alive and healthy at the age of 90 years. The paternal mother is deceased at the age of 84 due to some age-associated comorbidities such as diabetes and Alzheimer’s illness. The maternal grandparents are already dead and did not have any health issues, and the daughter is also healthy.
Social History: She is a widow following her husband’s death for five years ago. She is not having
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