Soap Note #1 Main Diagnosis: Urinary Tract Infection

Discussion Topic: Soap Note 1 “Urinary Tract Infection”

Requirements
Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:

Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:

Objective Data:
VITAL SIGNS:

GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:

ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• –
• –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals
References (in APA Style)
_______________-
Soap Note #1 Main Diagnosis: Urinary Tract Infection

PATIENT INFORMATION
Name: Jane Smith
Age: 26
Gender at Birth: Female
Gender Identity: Female
Source: Self-referred
Allergies: None known
Current Medications: None
PMH: History of recurrent UTIs
Immunizations: Up-to-date
Preventive Care: Annual gynecological exam
Surgical History: None
Family History: No significant family history
Social History: Non-smoker, occasional alcohol use
Sexual Orientation: Heterosexual
Nutrition History: Well-balanced diet, drinks plenty of water

Subjective Data:
Chief Complaint: Burning sensation with urination, frequent urination
Symptom analysis/HPI: The patient reports experiencing a burning sensation when urinating and needing to urinate more frequently than usual over the past three days. She reports no fever, chills, or back pain.

Review of Systems (ROS):
CONSTITUTIONAL: Reports feeling fatigued.
NEUROLOGIC: No complaints
HEENT: No complaints
RESPIRATORY: No complaints
CARDIOVASCULAR: No complaints
GASTROINTESTINAL: No complaints
GENITOURINARY: Burning sensation with urination, frequent urination
MUSCULOSKELETAL: No complaints
SKIN: No complaints

Objective Data:
VITAL SIGNS:
Temperature: 98.6°F
Blood pressure: 118/78 mmHg
Heart rate: 82 bpm
Respiratory rate: 16 bpm
Oxygen saturation: 98% on room air

GENERAL APPEARANCE: The patient appears well-nourished, alert, and oriented.
NEUROLOGIC: Cranial nerves II-XII are intact, and sensation and strength are normal in all extremities.
HEENT: Pupils are equal, round, and reactive to light. The oropharynx is clear.
CARDIOVASCULAR: Regular rhythm with no murmurs, rubs, or gallops.
RESPIRATORY: Clear to auscultation bilaterally.
GASTROINTESTINAL: Soft, non-tender, and non-distended abdomen.
MUSCULOSKELETAL: No swelling or deformities.
INTEGUMENTARY: No rash or lesions.

ASSESSMENT:
The patient presents with symptoms consistent with a urinary tract infection (UTI). The patient’s subjective and objective findings are suggestive of a UTI.

Main Diagnosis:
Urinary Tract Infection, Uncomplicated (ICD10 ICD-10-CM code: N39.0)

Differential diagnosis:

Interstitial Cystitis (IC)
Pyelonephritis
Sexually transmitted infections
Vulvovaginitis
PLAN:
Labs and Diagnostic Test to be ordered:

Urinalysis and urine culture to confirm the UTI diagnosis and determine the appropriate antibiotic treatment.
Blood tests such as complete blood count (CBC) and comprehensive metabolic panel (CMP) may be ordered if the patient develops fever, chills, or back pain, or if there is concern for a more severe infection.
Pharmacological treatment:

Antibiotic treatment with Nitrofurantoin 100mg twice daily for seven days.
Phenazopyridine 200mg orally three times daily for two days may be prescribed to help relieve urinary pain and discomfort.
Non-Pharmacologic treatment:

Increase fluid intake to flush out the urinary tract.
Avoiding irritants such as perfumed products, bubble baths, and feminine hygiene spr