NU632 SOAP NOTE #1

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Please provide the requested information on the template and enter the information on the template form attached. 

-Patient:

6year old white female

an already established patient at the clinic

-chief complaint:

pain with urination

-history of patient illness (please add more information to cover OLDCARTS format):

burning with urination and frequency x2 days. Pain and burning located in urethral area. urethral pain decreased when not urinating.  Rates current pain a 6 using the Wong-Baker Faces pain scale.

-diagnosis:

UTI

-Diagnostic test

Urinalysis

urine culture and sensitivity

-Education:

increase fluid intake

proper perineal hygiene

avoid irritants (bubble baths)

complete entire course of antibiotics

 

 

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