SOAP Note Patient with UTI

SOAP Note Patient with UTI

ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.

Client’s Initials: L.U

Age :65 years.

Race: African American

Gender: Female

Date of Birth: 08

Insurance: BlueCross BlueShield .

Marital Status: Married

Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.

CC: Pain and burning during urination.

HPI:

Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.

 

 

ROS

Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.

Eyes: Denies double vision, change in vision factors, or blurry vision.

Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.

Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.

Pulmonary: Denies

Gastrointestinal: c/o moderate to severe pain in the abdominal area.

Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.

Musculoskeletal: Denies any kind of pain

Integumentary & breast: Denies issues

Neurological: Denies issues

Psychiatric: Denies any kind of depression or mood swing

Endocrine: Denies having any problem

Hematologic/Lymphatic: Denies

Allergic/Immunologic: No Known allergy

 

Past Medical History:

· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.

· Denies history of chronic medical problems with father or mother.

· Preventative care: None indicated

· Surgeries: Denies

· Hospitalizations: Denies

· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.

Allergies: No known food or drug allergy

 

· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too and takes a similar treatment approach as his wife. Patient has four younger siblings who report not cases of physical conditions.

· Social History: Patient lives with her partner who is five years older than her. She works with an agency as janitor t where she has been working for the past ten years. Patient denies any illicit drug use. She said she has great support system surrounded with family and friends

Sexual history: Patient is sexually active has only one partner and they do not use kind of protection.

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Other:

Vital Signs: HR:70 BP:122/77 Temp:98.5 RR:18 SpO2:98% Pain:8/10

Height: 5ft 8 inches Weight: 150lb. BMI: 22.81.

 

Physical Exam

General Survey: Patient afebrile , no chest pain , no breathing problems or general weakness

A test indicated that patient had CVA tenderness upon palpitation. There was a suprapubic tenderness on the patient. A deep abdominal palpitation on the patient indicated tenderness.

Assessment

Diagnosis:

Assessment shows a clinical outcome of dysuria, suprapubic tenderness, and frequency and urgency of urination which indicates UTI (Sabih & Leslie, 2021). Noted no evidence of vaginal discharge, so therefore not consistent with vaginitis

 

Differential:

1. 2. Pyelonephritis (ICD-9 code 590.80). Pain in the lower abdomen especially increased due to urination. Pyelonephritis got eliminated since the patient did not have myalgia, nausea, vomiting, fever, or flank pain (Beahm et al., 2017

2. ). Overactive bladder (ICD 9-596.51). Suitable since patient reports highly frequent urination. An overactive bladder got eliminated since the urine dipstick gave a different result.

3. Vaginitis (ICD-9-616.10). Pain around the vagina area and lower abdomen. Ruled after dip stick urine.

 

 

 

Diagnosis:

Assessment shows a clinical outcome of dysuria, suprapubic tenderness, and frequency and urgency of urination which indicates UTI (Sabih & Leslie, 2021). Noted no evidence of vaginal discharge, so therefore, not consistent with vaginitis

 

 

Plan

Diagnostics/ Labs : To rule out UTI are urinalysis and urine culture.

A dipstick urine test shows presence of nitrite and leukocyte esterase

Treatment:

Double strength prescription of trimethoprim 160 mg and sulfamethoxazole 800 mg 2 times daily for three days. Patient can also take cranberry juice as studies has shown that it is very good to treat UTI because of its acid base properties.

Education:

· Instruct patient to avoid spermicidal products that increase risk of a UTI occurring.

· Teach patient to wipe the genital area from front to back after urination to avoid getting bacteria from anus to her virgina

· Teach patient to adhere to all treatment directions

· Teach patient and make sure patient understands the course of treatment which is 5 days, and to take all medication same time each day.

· Teach patient on the importance of drinking minimum of eight glasses of water per day. Add that this will help the body to fight bacteria..

· Teach patient to always urinate after sexual intercourse since that would flush out every bacterium from her urethra

· Teach patient to engage in physical exercises since this would improve her wellbeing and connection to proactive physical behavior. The patient should take note that both her parents have hypertension and should thus get her blood pressure reading taken during many intervals since this would allow detection of hypertension.

· Teach patient to reduce sexual intercourse with her partner especially since she is not aware if she is the only sexual partner her boyfriend has.

· Teach patient to always get routine vaccination against common illnesses since the technique would allow her to have proper wellbeing and management of her condition. .

· Teach patient to make a timetable of taking water since such fluids would increase urine and thus, that would flush out bacteria through the urethra.

· Teach patient to avoid sexual intercourse during the time she is taking medication to prevent any new infections. This will prevent patient from further getting affected in their ability to receive full bacterial treatment.

Follow Up And Recommendations

1. Return to the clinic within 7 days if symptoms persist.

2. Pap smear every 3 years for ages 21- 65.

3. Cranberry Juice can also be helpful it is rich in vitamin C and potent immune system booster, studies indicate that it balances the PH of the body with its acidic properties that helps fight infection.

 

 

 

 

 

 

References

Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., & Tsuyuki, R. T. (2017). The assessment and management of urinary tract infections in adults: Guidelines for pharmacists. Canadian pharmacists journal : CPJ = Revue des pharmaciens du Canada : RPC, 150(5), 298–305. https://doi.org/10.1177/1715163517723036 .

Sabih, A. & Leslie, S.W. (2021). Complicated Urinary Tract Infections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436013/

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