Looking for the best study guides, study notes and summaries about comprehensive health assessment. Advanced Practice Care of Adults? This document will take you through the template of conducting health assessment and writing SOAP Notes.
CC: “In the last two days, I have painful irritation on urination and increased urge to urinate.”
HPI: A 28 year old female presents to the office and reports that she has a two days, painful
irritation on urination and increased urge to urinate. The patient also states that she an abdominal
cramp and brown vaginal discharge with a bad odor that begun 7 days ago. The patient rates her
pain as 6 in a scale of 0 to 10. The patient’s symptoms have been aggravating with each passing
day making it hard for her to conduct her daily activities. The patient reports experiencing
similar signs and symptoms when she had urinary tract infection and states that all these
problems started after having an unprotected intercourse with her ex-boyfriend. The patient
denies unplanned weight changes, chills, night sweats, fatigue and fever. The patient reports that
she has not sort medical assistance yet and the worsening symptoms made her to come to the
clinic.
PMH/Medical/Surgical History:
Past diagnosis:
Diagnosed once with chlamydia.
Recurrent urinary tract infection x 3 (2021)
Diagnosed twice with gonorrhea.
Medications: None.
Surgery history:
Tubal litigation (2019)
Obstetrics:
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