“I’ve been having frequent, painful urination and some lower abdominal discomfort for the past two days”: SOAP NOTE.

A 29-year-old female presents with a 2-day history of dysuria, increased frequency of voiding, and a decreased level of comfort in the lower abdomen. She feels a burning sensation in the area of the bladder while urinating and has a powerful urge to urinate even when her bladder is not complete. Over 48 hours, the symptoms have grown progressively worse. The complaints include no fever, chills, or blood in the urine.

She says she has not changed anything in her diet or sexual activity recently. The patient has a history of recurrent urinary tract infections (UTIs) but never received any treatment through medical means. Still, she says she never had any history of kidney stones, pelvic trauma, or surgery. She is not sexually active at the moment and has denied any known exposures to sexually transmitted infections.

Allergies:

There is no known drug allergies (NKDA).

Medication Intolerances: None

Chronic Illnesses/Major traumas

There are no reported chronic illnesses.

Hospitalizations/Surgeries

No past hospitalizations or surgeries.

The patient does not have any known history of diabetes, hypertension, HTN, peptic ulcer disease, asthma, cardiologic disease, cancer, TB, thyroid trouble or kidney disease.

·        Mother has a history of hypertension.

·        Father has osteoarthritis.

·        No history of diabetes, kidney disease, or cancer in the family.

The patient drinks socially, one to two drinks per week, and smokes. She says she has no recreational drug use. As an office administrator, she lives in a suburban apartment with her partner and does not have any known hazardous material exposure. She is safe and her living arrangement is secure.

No weight change, fever, chills, or night sweats. Energy level is normal.

No chest pain, palpitations, or edema.

No rashes, bruising, or delayed healing. Skin is intact and healthy.

No cough, wheezing, or shortness of breath. No history of pneumonia or TB.

No blurring of vision or changes in eyesight. No corrective lenses required.

No nausea, vomiting, diarrhea, or abdominal pain. No recent changes in bowel habits.

No concerns of pain, hearing loss, or any ringing in ears.

Increased urinary frequency and dysuria. No vaginal discharge or abnormal menstrual cycle.

There are no complaints of sinus, dysphagia, or throat pain by the patient. There are no symptoms such as nose bleeds, nasal discharge, hoarseness or change in voice. Moreover, she has no recent dental procedures, dental disease, or gum problems.

No joint pain, swelling, or stiffness.

No lumps, bumps, or changes noted.

No syncope, seizures, or weakness. Cranial nerves intact. Good motor function.

The patient has no concerns about her HIV state, or history of blood transfusions. She has not had any night sweats or swollen lymph nodes and does not have any symptoms of excessive thirst or hunger. In addition, there are no issues of cold or heat intolerance.

No anxiety, depression, or recent stress. Reports feeling generally well emotionally.

The patient is healthy, alert. She does not have any acute distress or respond appropriately to questions. A bit somber at first, then more comfortable as the visit progresses.

Skin is brown, warm, dry, clean, and intact. No rashes or lesions observed.

Head is normocephalic and atraumatic. Extraocular movements are intact and scleral injection absent, the eyes are PERRLA. The ear canals are patent and the tympanic membranes are clear with a positive light reflex.

There is pink nasal mucosa without septal deviation. In the throat, there is no erythema or exudate of the oral mucosa is pink, moist.

Heart sounds are regular with S1 and S2, no murmurs or extra sounds. Capillary refill time is 2 seconds. Pulses are 2+ in all extremities, and no edema is present.

Symmetric chest wall, lungs clear to auscultation bilaterally.

Abdomen soft and non-tender. Active bowel sounds in all quadrants. No hepatosplenomegaly.

No lumps, bumps, or changes noted.

Bladder non-distended. Mild tenderness noted on palpation of the lower abdomen. No CVA tenderness.

The patient demonstrates full range of motion (ROM) in all four extremities as she moves around the exam room. No joint stiffness or limitations in movement are observed.

The patient is alert and oriented. No signs of acute neurological distress. Gait is normal, and speech is clear.

The patient is alert and oriented, appropriately dressed in clean slacks, a shirt, and coat. She maintains eye contact throughout the examination. Her speech is soft but clear, with a normal rate and cadence. She answers questions appropriately and exhibits no signs of psychiatric distress.

Urinalysis – pending

Urine culture – pending

Wet prep – pending

No specific tests performed at this time.

o   1. Cystitis – Cystitis refers to the inflammation of the bladder, often caused by a bacterial infection (Li & Leslie, 2023). The patient’s symptoms, including frequent urination and burning sensation, are consistent with cystitis, making it a strong contender in the differential diagnosis. Cystitis can be confirmed through urinalysis and urine culture.

o   2. Pyelonephritis – Pyelonephritis is an infection of the kidneys due to an ascending UTI spreading from the bladder (Belyayeva & Jeong, 2024). Even though the patient’s symptoms are not suggestive of fever or flank pain (common with pyelonephritis), pyelonephritis should be considered if symptoms worsen or systemic signs such as fever develop. White blood cells in the urine or bacteria also can help rule this out with a urinalysis.

o   3. Vaginitis – Vaginitis is inflammation of the vaginal tissues, mainly due to infections such as yeast and bacterial vaginosis (Hildebrand & Kansagor, 2022). Vaginitis may be diagnosed even though the patient denies vaginal discharge if symptoms include abnormal discharge or irritation. A wet prep or vaginal culture would help to distinguish this from a UTI.

Diagnosis

o   Urinary Tract Infection – A urinary tract infection (or UTI) is an infection of any part of the urinary system, the most commonly affected being the bladder (cystitis) and urethra (Bettcher et al., 2021). Considering the patient’s symptoms of dysuria (painful urination), urinary urgency, and lower abdominal pain, a UTI is most likely. Further diagnostic testing, such as a urine culture, should be done to confirm this and to identify the specific pathogen as well as the appropriate treatment.

§  Further testing – A urine test will identify white blood cells, bacteria, or blood in the urine, which can all be signs of a UTI. Testing for the specific pathogen in the urine culture will play a role in determining the particular antibiotic to use based on culture results. A wet prep may also be performed to discard other possible causes of urinary symptoms, such as vaginitis, by looking at the vaginal secretions for yeast or bacterial infections.

§  Medication – If a UTI diagnosis is made, a course of antibiotics is recommended. Nitrofurantoin or Trimethoprim-Sulfametheoxazole are common choices, usually given for 3-5 days based on culture results and clinical response (Bettcher et al., 2021). Completing the entire antibiotic course is crucial since it prevents recurrence and resistance.

§  Education – The patient should be taught to drink large amounts of fluids, especially water, to aid in the removal of bacteria from the urinary tract. Bacterial introduction should be reduced by emphasizing hygiene practices such as wiping from front to back after urination. Prevention of symptom exacerbation can be aided by avoiding bladder irritants such as caffeine, alcohol, spicy foods, and artificial sweeteners.

The patient should also be told about possible complications, such as pyelonephritis, and to consult a doctor if fever, back pain, or nausea and symptoms worsen.

§  Non-medication treatments – Encourage the patient to remain hydrated, practice good hygiene (from toe to back), and minimize any bladder irritants such as caffeine, alcohol, and spicy foods. Warm compresses applied to the lower abdomen may provide relief, but rest helps to heal. Treatment for the urinary tract may also include a urinary tract-friendly diet, including cranberry juice, which may reduce bacterial adhesion to the urinary tract.

The patient was taught in detail about UTI prevention and completed the drug. Treatment efficacy was reassessed, and symptoms were followed up in a follow-up appointment in 7 days.