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SOAP Note on Pelvic Inflammatory Disease

Name xxx

United State University

Course xxx

Professor xxxxx

Date xxx


SOAP Note on Pelvic Inflammatory Disease

ID:

Client’s Initials: G.H, Age: 23, Gender: Female, Race: Caucasian American, Date of Birth: January 01, 1999.

Subjective Data

CC: “I have vagina discharge, pelvic pain, and fever.”

HPI: Ms. G.H was accompanied by her boyfriend to the clinic. She reports having vaginal discharge that is malodorous, pelvic pain, and fever. She also complained of vaginal itching, and she also experienced a burning pain when urinating. She has experienced the pain for the last two weeks, and she described the rate of pain as 6/10. She experiences pain every time she has sex. However, she does not report changes in urinary regularity or persistency, hesitancy, recurrence, polyuria, or reduced urine stream. She has not used any medicine or treatment since the onset of pain. The symptoms started eight days ago. She is sexually active and describes having sex three weeks ago. She does not report any history of sexually transmitted diseases.

Past Medical Records: No major chronic diseases but has had mild flu, treated by home remedies such as ginger.

Surgery: No medical surgery.

Family History: She has a boyfriend. Her father is a retired military officer and smokes 1 pack of cigarettes a day, had a history of hypertension at the age of 45. Her mother is a retired teacher and has never had a serious chronic illness. She has two siblings, a brother 20 years old and a sister 15 years old. Both are in good health.

Social History: She is a college student. She goes to school from Monday to Friday and spends the weekend with friends and her boyfriend. She does not use hard drugs, nor does she smoke a cigarette. She does not drink alcohol. She lives alone in an apartment, which she says is safe.

Review of Systems

Constitutional: G.H is a Caucasian female adult with severe signs of physical affliction. She describes a moderate fever and reduced energy levels although, she denies chills, sweating at night, anorexia, and weight gain or loss.

Head: She has not encountered headaches, has not lost consciousness and has no numbness.

Eyes: She claims that there is no vision alteration, no need for eyeglasses, she has no eye ache, no redness, no glaucoma, no inflammation, blurred vision, and she has no abnormal tears in her eyes.

Ears: She does not have a hearing defect, no ringing, no fungal infections, no discharges, no aches, and she does not wear hearing aids. She does not

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