SOAP Note: Gonorrhea
Identifying Data and Chief Complain
A 25-year-old male, single and Hispanic patient comes to the clinic complaining of painful
urination and cloudy discharge from the penis. He reports “feeling burning pain with every
urination and a cloudy and yellowish discharge from th...
soap note gonorrhea identifying data and chief complain a 25 year old male
single and hispanic patient comes to the clinic complaining of painful urination and cloudy discharge
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NURS 3125
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Running Note: SOAP NOTE: GONORRHEA 1
SOAP Note: Gonorrhea
Identifying Data and Chief Complain
A 25-year-old male, single and Hispanic patient comes to the clinic complaining of painful
urination and cloudy discharge from the penis. He reports “feeling burning pain with every
urination and a cloudy and yellowish discharge from the penis. He describes the pain and burning
as moderate (4), symptoms started a week ago, with “spots in the underwears”. The patient
refers that is really “worry, because this is not the first time that I have a sexual transmission
disease”. He came to the office as a private patient, not using his medical insurance, because he
wants to keeps this situation away his parents, and his medical insurance is from his father’s
employer. He reports that is using acetaminophen 500mg for pain.
Subjective Symptoms
1. “Progressive pain with urination.”
2. The pain is associated with “burning and cloudy discharge from the penis.”
Subjective Data
Past medical history (PMH): Patient informs that he is healthy from childhood. He only
remembers that he suffered from varicella. He did not use protection during sexual intercourses
with some partners, steadies and occasional. Patient refers no appetite or weight changes. No
other chronic diseases reported.
Family history: His mother is a 46-year-old woman with no history of chronic diseases. His
father is a 62-year-old man with bipolar and heart diseases with an open heart surgery/three
bypasses three years ago. Patient’s brother is 28-year-old with no history of chronic diseases.
Grandmother, from mother’s side, is alive and has hypertension and diabetes mellitus. Grandfather
from mother’s side, had a cerebrovascular accident (CVA) ten years ago, he doesn’t has other
, SOAP NOTE: GONORRHEA 2
chronic diseases. He doesn’t has knowledge about his other grandparents from father’s side
health, grandmother alive.
Past social history (PSH): The patient doesn’t smoke but drink alcohol during weekends (four
drinks approximately per activity). He is Catholic. The patient works part-time in a store as sales
associate 20 hours/three days a week. He is studying a master degree in psychological
counseling, this is his second year. He goes to the gym three or four times a week. He states that
he has a diet high in protein and fiber, low in carbohydrates and includes lactate: milk, cheese and
butter. He is sexually active with different partners and doesn’t use protection for sexual
transmitted infections (STI) like condoms.
Immunization: All vaccines are up to date including Hepatitis B and Influenza (a month ago).
Allergies: No known allergies (NKA).
Surgical history: HPV warts were removed from anus in two different occasions. No other
surgeries history.
Medication history: Patient refers that he was prescribed preventive treatment with antibiotics
for Chlamydia and Syphilis (exposed to both with an infected partner).
Subjective Review of Systems
Constitutional: Patient indicates he has pain, no chills, no weight changes and no fatigue.
Skin: He indicates that doesn’t have lesions, acne, dry skin, pruritus, no nodules, no new moles,
no dry hair and no eczema.
HEENT: He indicates no hear difficulty or tinnitus, no congestion, no dental or swallowing
problems and no vision problems with eyeglasses.
Respiratory: He indicates that doesn’t have rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: He indicates that doesn’t has edema, tachycardia, bradycardia, chest pain,
orthopnea or palpitations.
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