CONPH NSG6330/NSG6430 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Suleiny Saez Course: NSG6430
Patient Name: (Initials ONLY) CD Date: 9/7/2023 Time: 9 am
Ethnicity: Latino Age: 28 years Sex: Female
SUBJECTIVE (must complete this section)
CC: "I have pain and pressure on my lower abdomen and pelvis, painful urination, a strong and constant need to
pass urine,."
HPI: A 28-year-old female arrives at the clinic with lower abdomen pain and discomfort that she evaluates as a 4/10.
She
S u r g er i e
al s o m e n tions that she has been having an increased urge to urinate and is able to pass a small amount of
urine. The patient claims that she feels pelvic pressure and pain upon passing urine. The patient noticed the symptoms
five days ago, which have worsened over time. The patient says she has done nothing to alleviate symptoms because she
expected them to go away independently, but they have deteriorated. She has tried drinking a lot of fluids, but her
symptoms remain.
Patient denies fever and chills, as well as nausea and vomiting, vaginal discharge, upper back, frank discomfort, or
blood
in her urine.
Medications: none
Previous Medical History: no
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