Soap Notes and Clinical Practice Guidelines

Running head: SOAP 1
Soap Notes and Clinical Practice Guidelines
Name of Student
School

Soap Notes and Clinical Practice Guidelines
Subjective
The chief complainant is an 18-year-old female who mainly complains of "I have been
having dysuria and lower abdominal cramping."
History of current illness: the patient has been having such complications for the last five
days. However, these complications have been asymptomatic though. The patient has not
undergone severe illness and surgery lately.
Medical condition: Dysuria
Medications: None
Allergies: None
Regular cycles 3-4/28 cramping present.
Objective
Physical Examination
General Appearance: The lady was well developed and alert
Vital signs: wt. 175lob. Ht. 5’4’, temp 98.9, RR, 87, P. 18, HR, 70, BP 120/77
Eyes: Patient had a white sclera and pink conjunctiva; all the pupils were round and qual.
Ear, nose, mouth, and throat: Ears had no lesion, denies any discharge, no redness, had no
swelling, the patient had no hearing difficulties. Nose; had mucus had no inflammation, denies
any lesion. Mouth: was pink and moist, had well maintained dental hygiene, throat: denies
inflammation, tonsils were WNL denied erythema, had no masses.