What details did the patient or parent provide regarding the personal and medical history?

Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment. 
Select a patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note. 
Assignment

Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. 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? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

SAMPLE SOLUTION

Patient’s Initials: AK

Age: 27 years

Sex: Female

CC: Genitourinary disorder

Subjective Data

History of Patient Illness

The patient presents to the clinical care setting with a report of a 2-day burning and pain when urinating. Also reports intense abdominal pain and has also had vaginal discharge in the last three days. She states that the signs begun three days ago after she had unprotected sex. The discharge was brown with notable odor (Israel, 2014).

Medical History: According to the patient, the problem recurred as it had also happened two years ago. According to the patient, she has a reported case of gonorrhea X2, and gravida IV para III

The Past Surgical History: there is no evidence of past surgical history according to the patientSocial History: Although AK is currently single, she has had a history of multiple sex partners. She reports to have been in two previous relationships and the boyfriends were often unfaithful. Currently, she is being housed by one of the boyfriends who is a stay-at home…