12SOAP Note Patient with UTIUnited State

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SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx










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 a ...

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SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical
Practicum
Dr. xxxx










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

2. 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

3. 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

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

5. 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.

6. · 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:

7. https://www.ncbi.nlm.nih.gov/books/NBK436013/


Clinical Documentation Template

Directions:Students may use this general SOAP note template or
their own. Save a copy to your device to alter the document.
Use APA when called for by the rubric or assignment prompt.
The APA title page will be the first page, and the template will
start on the second page. End with your APA formatted
references. Keep in mind this template is structured for an
average, problem-focused visit. This template will not be
adequate for some special populations and situations
(newborns/pregnancy visits/child wellness, etc.). Students need
to use good clinical judgment and make additional headings and
sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the
US Department of Health and Human Services/CMS:
Documentation Guidelines - Reimbursement

Delete all text in red - these are instructions and not part of the
SOAP document.



Student Name and clinical course: (If no title page):
______________________

ID:
Client’s Initials*:_______Age_____
Race__________Gender____________Date of
Birth___________
Insurance _______________ Marital Status_____________
*It is recommended to include false initials and use Jan 1,
XXXX (correct year) to protect client confidentiality. Include

8. brief statement on whether the patient came to the clinic alone
or accompanied, and if so by whom, and whether they are a
reliable historian.

Subjective:


CC: Patient’s own words, a few words, a sentence or less.
Example: “cough and fever”

HPI:
In paragraph format, including at the minimum OLDCARTS.
Please start with demographics: AA, a 29 y.o. Asian female
presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating
factors or Associated symptoms, Relieving Factors, Treatment,
and Timing, Severity. Include any pertinent positives or
negatives.

ROS (write out by system): Comprehensive (>10) ROS systems
for wellness exams or complex cases only. Do not include all 14
systems for every SOAP unless needed - review and document
the pertinent systems. Do not include diagnoses - those belong
in PMH. The below categories are per CMS guidelines.


Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:

9. Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:


Past Medical History:
· Medical problem list

· Preventative care: (if applicable to the case - Paps,
mammography, colonoscopy, dates of last visits, etc.)

· Surgeries:

· Hospitalizations:

· LMP, pregnancy status, menopause, etc. for women

Allergies:
Food, drug, environmental

Medications: include names, doses, frequency, and routes, and
reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as
applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every
pt about tobacco use)

Other: -Other social history as applicable to each case

10. (diet/exercise, spirituality, school/work, living arrangements,
developmental history, birth history, breastfeeding, ADLs,
advanced directives, etc. Exercise your critical thinking here -
what is pertinent and necessary for safe and holistic care)

Objective

Vital Signs: HR BP Temp RR SpO2
Pain

Height Weight BMI (be sure to include
percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the
date of labs - might be POC tests from today

Physical Exam (write out by system):

Start with a general survey:


Assessment
(you will often have more than one diagnosis/problem, but do
the differential on the main problem)

Differentials (with a brief rationale for each):
1.
2.
3.

Diagnosis (may have more than one, include ICD-10 if rubric or
as your instructor specifies)

Plan(4 pronged-plan for each problem on the problem list)

Diagnostics:

11. Treatment:

Education

Follow Up:



List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator,
ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when
sick
E. Return to clinic in 3-4 months to reassess