09 Nov Episodic/Focused SOAP Note Template (Case study)
Case study:
CC: dysuria and urinary frequency
HPI: RG is a 30-year old female with increased urinary frequency and dysuria that began 3 days ago. Pain is intermittent and
described a burning only in urination, but c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for
pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3 years ago.
PMH: UTI 3 years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain
FHx: Mother breast cancer (alive) Father hypertensioon (alive)
Social: Single, no tobacco, works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
Review of Systems:
* General: Denies weight change, positive for sleeping difficulty because of the flank pain. Feels warm.
* Abdominal: Denies nausea and vomiting. No appetite
Objective:
* VS: Temp 100.9; BP: 136/80; RR 18: HT 6’0″; WT 135lbs
* Abdominal: Bowel sounds present x4. Palpation pain in both lower quadrants. CVA tenderness
* Diagnostics: Urine specimen collected, STD testing
Assessment:
* UTI
* STD
Assignment:
– Analyze the subjective porition of the note. List additional information that should be included in the documentation.
– Analyze the objective portion of the scenerio. List additional information that should be included in the documentation
– Is the assessment supported by the subjective and objective informationo? why or why not?
– Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
– Would you reject/accept the current diagnosis? why or why not? identify three possible conditions that may be
considered as a differential diagnosis for this patient. Explain your reasooning using at least three different references
from current evidence-based literature
