Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:Subjective: What details did the patient provide regarding or her personal and medical history? Objective: What observations did you make during the physical assessment?

Select a patient that you examined during the last four weeks. With this patient in mind, address the following in a SOAP Note:Subjective: What details did the patient provide regarding or her personal and medical history?
Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?
(THE TOPIC HERE IS URINARY TRACT INFECTION (UTI) )

please use this format

Comprehensive SOAP Template

Patient Initials: Age: Gender: F

Introduction –Purpose:

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies: Seafood, iodine

Past Medical History (PMH):

Past Surgical History (PSH): Denies.

Sexual/Reproductive History (Obstetric):

Personal/Social History:

Immunization History and Preventive Care:

Significant Family History:

.

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular:

Breasts:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Dermatological:

Hematological and Lymphatic:

Endocrine:

Allergy and Immunology:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General appearance:

HEENT:

Neck:

Lymphatics:

Breasts:

Chest:

Heart:

Abdomen:

Neurological:


 

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