SOAP Note – Urinary Tract Infection

ID: DZV DOB: 1968 Age 56. Race: Caucasian Gender: Male

The patient presented to the clinic alone. He appears to be a reliable historian.

Subjective:

CC: “I am experiencing an increased feeling of peeing even after leaving the toilet, and sometimes peeing a lot. My lower stomach is also hurting me.”

HPI:

DZV is a 56-year-old Caucasian male presenting with complaints of urinary urgency, urinary frequency, and pain in the lower abdominal area. These manifestations began three weeks ago. The pain is located primarily in the suprapubic regions. The symptoms have been on and off over the past three weeks but have increased significantly in the past week. The pain is diffuse and exists during the urination process and even after urinating. The symptoms are improved by voiding and aggravated by urine holding. They are present most of the day and are more severe during urination.

Past Medical History:

Medical problem list

Type 2 Diabetes Mellitus

Preventative care:

Routine prostate examination in January.

Annual flu vaccination and booster dose of COVID-19 vaccine last month.

Surgeries:

No reports of surgeries

Hospitalizations:

He was hospitalized 15 years ago for hypoglycemia.

Allergies: No known drug or food allergies.

Medications: The patient is on metformin 500mg, taken orally every 12 hours. He is also on an unidentified over-the-counter analgesic to manage his pain. He is also on 100g of Nitrofurantoin every 12 hours.

Family History: DZV has no family history of any urinary or reproductive tract infection.

Social History:

Sexual history and contraception/protection: DZV is sexually active. He engages in unprotected sex regularly and had been involved in sexual intercourse with an identified female weeks before the onset of his symptoms. He sometimes uses condoms during intercourse but has a specific dislike for them.

Chemical history (tobacco/alcohol/drugs): The patient is a binge-alcohol drinker and a social smoker. He denies taking any illicit substances or narcotics.

Others: The patient has been living alone since his divorce. He has three children, all of whom live with his wife.

ROS

Constitutional: No reports of weight loss, fever, or chills.

Genitourinary: The patient reported complaints of a strong urge to urinate, even after leaving the toilet, and frequent urination. He also reported having suprapubic pain. There were no reports of hematuria, dysuria, malodorous discharge, and dyspareunia. There are also no reports of urinary incontinence.

Neurological: No reports of neurological complications such as seizures, memory problems, dementia, or personality changes.

Objective

Vital Signs:

HR: 89 beats per minute, 88 bpm on repeat.

BP: 134/83mmHg, 129/82mmHg on repeat.

Temp: 99.0 degrees F

RR: 16 breaths per minute

SpO2: 97%

Height: 6’0

Weight 176.0 lbs

BMI: 23.5

Laboratory Findings

Urinalysis for DZV on 4/30/2024: Performed to evaluate apparent UTI

Test	Result
Blood	Negative
Leukocytes	Negative
Nitrite	Negative
Protein	Negative
pH	6
Specific gravity	1.030
Glucose	Negative
Ketones	Negative
Bilirubin	Negative
Urobilinogen	0.6 mg/dL

Complete Blood Count for DZV on 4/30/2024: CBC was performed to ascertain the presence of an inflammatory response and/or an infection. The test was necessitated after a negative urinalysis.

Hematology	Result	Normal range
Red cell count	5.5 x 10¹²/L	4.5–5.7
White cell count	12 x 10⁹/L	4.0–10.0
Hemoglobin	156 g/L	133–167
Hematocrit	0.49	0.35–0.53
MCV	93 fL	77–98
MCH	31.9 pg	26–33
MCHC	351 g/L	330–370
RDW	13.5%	10.3–15.3

Physical Exam

General survey: The patient is alert and responsive to the interview questions. No signs of fever, fatigue, or weight loss. There were also no signs of jaundice.

Abdominal and pelvic: The abdominal wall is symmetrical. There is also no sign of scars, skin color inconsistencies, engorged veins, or abdominal stretch marks. There were no signs of abdominal distension or abdominal masses on visual inspection. The Cullen sign and the Grey Turner signs were also not seen. Low-pitched and gurgling sounds were heard during the auscultation of the abdomen. No bruit sounds were heard on auscultation of the areas above the abdominal aorta and the renal arteries. Tympanic sounds were heard on percussion. Light and deep palpation of the flanks revealed tenderness and pain. There were, however, no signs of abdominal masses, spleen or liver enlargement, or tenderness in the McBurney’s point.

Bladder exam: There were no signs of full or hyper-extended bladder on visual inspection. There were also no signs of fullness in the costovertebral angle or indentations on the skin above the bladder.

Neurological: The patient is alert and oriented to place, time, and event. His memory and judgment are intact.

Assessment

Differentials

Interstitial cystitis N30.10: Interstitial cystitis is an inflammatory condition that primarily affects the bladder. It is characterized by urinary frequency, urgency, and discomfort. Suprapubic pain or pressure may also be apparent in this disease state. According to the American Urological Association, interstitial nephritis is a diagnosis of exclusion that is arrived at after other urinary and reproductive tract infections have been excluded (Clemens et al., 2022). Patients presenting with manifestations of suprapubic pain, urinary frequency, and urgency, and those who do not improve on standard therapy may be considered to be having the disease (Ueda et al., 2021). The patient in the case presented has urinary frequency, urgency, and suprapubic pain. Also, his condition did not improve on management with standard therapies for UTIs. This warranted the inclusion of this differential.

Acute Pyelonephritis N10: Acute pyelonephritis is an inflammatory condition of the kidney. It is associated with bacterial infections and occurs as a complication of a urinary tract infection in the ascending loop (Resende, 2020). The hallmark signs and symptoms of the disease include flank pain, fever, a burning sensation on urination, nausea and vomiting, and urinary frequency and urgency (Hudson & Mortimore, 2020). The patient in the case presented had urinary frequency, urgency, and flank pain, warranting the inclusion of this differential. This differential was, however, ruled out due to the absence of other supporting features such as fever and dysuria.

Sexually transmitted diseases A64: Sexually transmitted diseases are a spectrum of infections that follow sexual intercourse and result from the transmission of an organism between sexual partners. Genital herpes, chancroid, Trichomonas, gonorrhea, syphilis, and chlamydia are the most common and significant STDs affecting the reproductive tract (Wihlfahrt et al., 2023). The common features of STDs include dysuria, urinary frequency, urinary urgency, flank pain, fever, and malodorous discharge (Fasciana et al., 2022). The patients in the case presented had flank pain, urinary frequency, and urinary urgency. This warranted the inclusion of this differential. Labwork and STD screening are required to rule out this diagnosis.

Diagnosis: The presumptive diagnosis is interstitial cystitis N30.10. The patient’s manifestations were consistent with those of interstitial cystitis. Additionally, the urine culture tests were negative for pyuria, ruling out acute pyelonephritis. STD screening was also negative, ruling out the STD diagnosis.

Plan

Interstitial Cystitis N30.10

Laboratory workup: Used to rule out other disorders that may be causing the symptoms reported in the patient. A complete blood count can help ascertain the presence of an inflammatory process that characterizes the disease (Clemens et al., 2022). Urinalysis can help detect the presence of pyuria, commonly suggestive of acute pyelonephritis and highly suggestive of acute pyelonephritis (Hudson & Mortimore, 2020). STD screening for chlamydia may help rule out Chlamydia trachomatis, which is a common UTI with symptoms similar to those seen in the patient. STD screening will also help in ruling out other possible STDs.

Cytoscopy: Cytoscopy will be ordered if there is suspicion of bladder cancer or bladder outlet obstruction. It can help rule out malignancies, outlet obstructions, and strictures.

Treatment: The patient will be started on pain management therapy using acetaminophen 1g, taken every 8 hours, and Ibuprofen 400mg, taken orally every 8 hours. He will also be started on amitriptyline, 10mg taken every 24 hours, to manage his condition.

Patient Education: The patient will be educated on the disease process and the available therapeutic modalities. They will be told that interstitial cystitis is a complex disease and that a multimodal approach will be used in managing their condition. Conservative measures are targeted at alleviating disease symptoms (Garzon et al., 2020). This involves dietary adjustments to minimize high acid-containing foods and alcohol, pelvic floor relaxation techniques, and stress reduction (Garzon et al., 2020). When starting the medication, the patient should be advised to take his medications at night as amitriptyline has sedative properties and could interfere with daytime activities.

Follow-up: The patient is expected to return for follow-up after one week to allow caregivers to ascertain their response to the pain medications given.

References

Clemens, J. Q., Erickson, D. R., Varela, N. P., & Lai, H. H. (2022). Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Journal of Urology, 208(1), 34–42. https://doi.org/10.1097/ju.0000000000002756

Fasciana, T., Capra, G., Lipari, D., Firenze, A., & Giammanco, A. (2022). Sexually transmitted diseases: Diagnosis and control. International Journal of Environmental Research and Public Health, 19(9), 5293. https://doi.org/10.3390/ijerph19095293

Garzon, S., Laganà, A. S., Casarin, J., Raffaelli, R., Cromi, A., Sturla, D., Franchi, M., & Ghezzi, F. (2020). An update on treatment options for interstitial cystitis. Menopausal Review, 19(1), 35–43. https://doi.org/10.5114/pm.2020.95334

Hudson, C., & Mortimore, G. (2020). The diagnosis and management of a patient with acute pyelonephritis. British Journal of Nursing, 29(3), 144–150. https://doi.org/10.12968/bjon.2020.29.3.144

Resende, G. (2020). Acute pyelonephritis. Radiopaedia.Org. https://doi.org/10.53347/rid-82333

Ueda, T., Hanno, P. M., Saito, R., Meijlink, J. M., & Yoshimura, N. (2021). Current understanding and future perspectives of interstitial cystitis/bladder pain syndrome. International Neurourology Journal, 25(2), 99–110. https://doi.org/10.5213/inj.2142084.042

Wihlfahrt, K., Günther, V., Mendling, W., Westermann, A., Willer, D., Gitas, G., Ruchay, Z., Maass, N., Allahqoli, L., & Alkatout, I. (2023). Sexually transmitted diseases—an update and overview of current research. Diagnostics, 13(9), 1656. https://doi.org/10.3390/

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Question

Create a pretend SOAP NOTE for URINARY TRACT INFECTION and please make the treatment plan, and education as specific as possible with reference as that is how we will be graded more. I attached a student sample completed SOAP NOTE.

SOAP Note – Urinary Tract Infection

2.) Please follow the correct format on the STUDENT SAMPLE COMPLETED SOAP NOTE that I attached.
3.) Treatment, Education, and Follow-Up plan should be very SPECIFIC medication like what type of medication and dosage and frequency and must use a clinical guideline (please see the example). Make sure that the treatment has references and plagiarism plagiarism-free

If it’s a FOCUS ASSESSMENT, just do the ROS and Physical Exam related to the complaint. You don’t need to do the complete system, just focus on what system to check that is related to the complaint of the patient on urinary tract infection.

Please please follow the rubric on the SOAP NOTE

SOAP Note – Urinary Tract Infection