In the past, it has been easier for students to write the analysis in narrative form. However, I have had students use the SOAP format and include the missing data. Either way is fine if you have the required information. Please use the rubric for guidance to make sure you have everything that is required. This is what I will use for grading.
Genitourinary Assessment
CC: Increased frequency and pain with urination
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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
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