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Fictional SOAP Case – Non-Medical Interpretation

by | Mar 26

Read the following fictional SOAP note written by the primary care physicianand write a non-medical interpretation of what it says.

S: Pt states that she occasionally leaks urine when she sneezes. No dysuria. Feels she has problems with nocturia. Denies constipation. One sexual partner and uses condoms. Periods regular- last period 2 weeks ago.

O: No flank tenderness bilateral. No suprapubic tenderness. VS WNL. Urine sample obtained and no gross hematuria noted. DRE and pelvic exam normal. Neuro exam WNL

A: This 40 YO female presents with asymptomatic involuntary urination that she has been experiencing for about 6 months. She did not mention it during her last visit, as she was embarrassed to discuss it. She is afebrile, no general malaise, is well nourished and has no flank or abdominal tenderness. Findings suggest stressincontinence.

P: Urine to lab for urinalysis. Patient instructed to keep diary of leakage- note time and foods and liquids consumed. Instructed in Kegel’s exercises. Pt to return in 2 weeks . May discuss possible cystometry.

Instructions

Write a non-medical interpretation of what the above SOAP note says. What method(s) did you use to interpret the clinicalinformation? What were some challenges in interpreting the information?

This is an original work and has not been previously published or shared with any other source. This work is to be treated as a guideline to assist you with this assignment. At no time is it intended to be used as the completion of homework or final submission quality work and I discourage you from using it as such. Points made and topics discussed in this work should be researched further and validated by the student prior to utilizing it in their own work which will be complied for final submission to their schools.
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Subjective: This patient occasionally leaks urine when she sneezes. She states …

In this problem, the case is analyzed based the subjective, objective, assessment, and plan, coming from a non-medical interpretation, along with what method was used to interpret the information and what challenges existed in this interpretation. Approximately 326 words of original content.

  

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