Soap Note

Soap Note

Hind Errajai is a 47 year old male who comes to our facility complaining about having lower abdominal pain accompanied for burning urination for several days. The patient reports that the pain has an intensity of 4/10 on the numerical scale of 0/10, relieve with Tylenol 500mg 2 tabs every 6 hours and irradiate *radiates to the low back.

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He says that he has frequent urge to urinate, he also states that when he goes to urinate is painful. The pain killers Tylenol?? have been giving him a temporary solution relief but have not given him a lasting solution. The patient denies presence of hematuria or penile discharge, denies fevers, vomiting or nausea. CVA Tenderness
Name:Hind Errajai Date:01/18/2019 Time:10:00 Am
Age:48 Sex: Male
"Urinary Tract INfection"
Medications:Currently not taking any prescribed medication
OTC: Tylenol 500 mg take 2 tabs PO BID every 6 hours prn for pain
PMH Allergies: No Know Allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: HTN
Hospitalizations/Surgeries: Patient has no significant past medical history
Family History
Mother: HTN
Father: HTN and Diabetes
Social History The patient is married lives with his wife and 2 children; he works as a cook at Denny’s restaurant. Denies drinking alcohol and denies smoking cigarettes.

No weight change, fatigue, fever, chills, night sweats, good energy level, good appetite.
Cardiovascular Denies chest pain, palpitations, orthopnea, edema.
Skin Denies rashes, bruising, bleeding or skin discolorations. No lesions. Respiratory
No cough, wheezing, hemoptysis or dyspnea.
No corrective lenses, no blurring vision, no visual changes.
No abdominal pain, denies diarrhea o constipation. Denies nausea or vomitin.No history of hepatitis, hemorrhoids, eating disorders, ulcers or black, tarry stools.
Denies ear pain, hearing loss, ringing in ears, or discharge.
Refers ?? This is not clear, I do not understand what you are trying to communicate burning urination, urinary frequency and urgency, no change in color of urine. PSA done two months ago: negative
Denies Sinus problems, dysphagia, nose bleeds or sore throat.
Referes back pain. Denies joint swelling, stiffness, fracture osteoporosis
No lumps, bumps, or changes.
Denies syncope, seizures, transient paralysis, paresthesias, or black-out spells.
HIV status: Negative No bruising, blood transfusion hx, night sweats, swollen glands. Denies increase thirst, increase Hunger. N cold or heat intolerance.
Denies depression, anxiety, sleeping difficulties or suicidal ideation.


Elliott, S., Roth, J., Stoffel, J., Lenherr, S., Presson, A., Welk, B., & Myers, J. (2018). PD04-07 URINARY TRACT INFECTION FREQUENCY AND SEVERITY IS ASSOCIATED WITH BLADDER MANAGEMENT METHOD IN SPINAL CORD INJURY. The Journal of Urology, 199(4), e80.

English, E. M., Espiritu, K., Seiler, K., Morgan, D., Berger, M. B., Cronenwett, A., & Foxman, B. (2018). 57: Changes in lower urinary tract symptoms and urinary incontinence following benign gynecologic surgery. American Journal of Obstetrics and Gynecology, 218(2), S929-S930.

Harlow, B. L., Bavendam, T. G., Palmer, M. H., Brubaker, L., Burgio, K. L., Lukacz, E. S., ... & Hooton, T. M., & Gupta, K. (2018). Acute complicated urinary tract infection (including pyelonephritis) in adults. UpToDate.

Lalueza, A., Sanz-Trepiana, L., Bermejo, N., Yaiza, B., Morales-Cartagena, A., Espinosa, M., ... & Orellana, M. Á. (2018). Risk factors for bacteremia in urinary tract infections attended in the emergency department. Internal and emergency medicine, 13(1), 41-50.

Moustafa, A., Li, W., Singh, H., Moncera, K. J., Torralba, M. G., Yu, Y., ... & Pieper, R. (2018). Microbial metagenome of urinary tract infection. Scientific reports, 8(1), 4333.

Sutcliffe, S. (2018). The prevention of lower urinary tract symptoms (PLUS) research consortium: A transdisciplinary approach toward promoting bladder health and preventing lower urinary tract symptoms in women across the life course. Journal of Women's Health, 27(3), 283-289.

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