Episodic SOAP Note
T. S., 32 years old, female
Subjective
Chief Complaint (CC): “burning pain during urination and increased frequency.”
History of Present Illness (HPI)
T. S. is a 32-year-old woman who reports having dysuria, frequency, and urgency for the past two days. She has not tried anything to relieve discomfort. She had similar symptoms several years ago. She is sexually active and has been with new partners in the past three months.
Medical History
Childhood History: No history of chronic or major reoccurring conditions
Medical History: None
Surgical History: Tonsillectomy in 2001, Appendectomy in 2020
PMH: UTI three years ago
PSHx: Hysterectomy at 25 years
Medication: Tylenol 1000 mg PO every 6 hours for pain; 1 tablet Centrum Multivitamin Daily; Protonix 20mg PO daily for GERD.
FHx: Mother breast cancer (alive), father hypertension (alive)
Social History: Single, no tobacco, works as a bartender, positive for ETOH
Allergies: PCN and Sulfa
LMP: N/A
Review of Systems (ROS)
General: Denies weight change, positive for sleeping difficulty because of the flank pain. Feels warm.
Eyes: Denies vision changes, double vision, or blurry vision
Ears, nose, throat: Denies changes in hearing, runny nose, sore throat
Respiratory: Denies cough, dyspnea
Cardiovascular: Denies fatigue, chest pain. No history of hypertension
Abdominal: Denies nausea and vomiting. Reports having no appetite
GU: Urinary frequency, dysuria, urgency for two days.
Objective
VS: Temp 100.9; BP: 136/80; RR 18; HT 6’.0”; WT 135lbs
Appearance: T. S. is alert, well oriented, and cooperative. She maintains eye contact, is appropriately dressed, and is well-groomed. Looks her stated age.
HEENT: Head: No lesions, trauma, rashes, normocephalic. Eyes: No redness or discharge, sclera are white bilaterally. Ears: Hearing is normal. Nose: No inflammation, the mucosa is pink and moist. Throat: mucosa is pink, no lesions or inflammation.
Abdominal: Bowel sounds present x 4. Palpation pain in both lower quadrants. CVA tenderness.
Diagnostics: Urine specimen collected, STD testing.
Assessment
Primary Diagnosis
The primary diagnosis for the patient is a urinary tract infection (UTI). UTIs are infections common in sexually active women (Storme et al., 2019). Moreover, the patient has had a UTI before, which increases the risk of reinfection (Storme et al., 2019). The patient reports dysuria, urgency, and frequency – the main symptoms of a UTI (Behzadi et al., 2019). The patient also has a fever which suggests a risk of kidney infection. Moreover, the patient reports abdominal pain and CVA tenderness, pointing to the diagnosis of a complicated UTI as the most possible.
Differential Diagnoses
The first potential differential diagnosis is a pelvic inflammatory disease. It is commonly caused by sexually transmitted infections, such as gonorrhea and chlamydia (Behzadi et al., 2019). Its symptoms are fever, abdominal pain, dysuria, bleeding, and vaginal discharge (Behzadi et al., 2019). Although it may present without symptoms, the patient does not report bilateral abdominal pain, discharge, or irregular bleeding, which eliminates the diagnosis. Dysuria, fever, and CVA pain suggest the possibility of kidney stones (Behzadi et al., 2019). However, this diagnosis can be eliminated because the patient does not have blood in the urine, and the CVA region is tender, but there are no sharp pains. Similarly, the diagnosis of vaginitis was considered and eliminated due to the absence of vaginal discharge and odor change.
Treatment Plan
Medications: Ciprofloxacin 250 mg orally every 12 hours for seven days for the infection (Abou Heidar et al., 2019).
It is vital to instruct the patient to take the prescribed medications according to the plan and not stop taking the antibiotic even if the symptoms disappear. The patient should drink more fluids, mainly water, to achieve proper hydration and flush out bacteria from the urinary tract (Abou Heidar et al., 2019). The patient should be advised to minimize using fragrant products for genital hygiene and to follow a proper hygiene regimen (Abou Heidar et al., 2019). She may need to avoid caffeinated drinks, alcohol, and soft drinks to reduce the risk of bladder irritation.
References
Abou Heidar, N. F., Degheili, J. A., Yacoubian, A. A., & Khauli, R. B. (2019). Management of urinary tract infection in women: A practical approach for everyday practice. Urology Annals, 11(4), 339-346. Web.
Behzadi, P., Behzadi, E., & Pawlak-Adamska, E. A. (2019). Urinary tract infections (UTIs) or genital tract infections (GTIs)? It’s the diagnostics that count. GMS Hygiene and Infection Control, 14. Web.
Storme, O., Tirán Saucedo, J., Garcia-Mora, A., Dehesa-Dávila, M., & Naber, K. G. (2019). Risk factors and predisposing conditions for urinary tract infection. Therapeutic Advances in Urology, 11, 19-18. Web.