The assignment for this week is an analysis of a SOAP note for the genitalia/rectum.
The assignment for this week is an analysis of a SOAP note for the genitalia/rectum. As in the previous SOAP note analysis, this should be completed in a narrative format and answer all the questions listed in the assignment within the module. Please remember to use the rubric to complete the assignment.
Genitourinary Assessment:
Subjective:
CC: Increased frequency and pain with urination
HPI: T.S. is a 32-year-old woman who reports that for the past two days, she has dysuria, frequency, and urgency. Has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
Medical History: None
Surgical History:
-Tonsillectomy in 2001
-Appendectomy in 2020
Review of Systems:
General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
Abdominal: Denies nausea and vomiting. No appetite
Objective
VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
Pelvic Exam:
mild tenderness to palpation in the suprapubic area
bimanual pelvic examination reveals a normal-sized uterus and adnexae
no adnexal tenderness.
No vaginal discharge is noted.
The cervix appears normal.
Diagnostics:
Urinalysis
STI testing
Papsmear
Assessment:
UTI
STI
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
RUBRIC:
With regard to the SOAP note case study provided and using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature:
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