Evidence-Based Clinical Intervention: SOAP Note: Urinary Infection

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Urinary Infection
Name:  B. T Date: March 29, 2017 Time: 2:00 pm
Age: 29 years old Sex: White Female
CC: “I think I am having a urinary tract infection” You may find this article Nursing SOAP Note Writing Service useful.
HPI: The patient notes that she started having the symptoms two days ago. She claims that she realized that she was visiting the toilet more than usual. The patient reports increased urination from the normal four times every day, but for the past two days the urge to go to the toilet has risen to between 6 and 8 times a day, though she has not managed to produce much urine whenever she went to the toilet. She also reports feeling a growing burning sensation during urination, particularly when she is able to produce at least some urine. She started having lower abdominal pain a day before the visit which worried even more and she came to our office to book an appointment. She states that the pain worsens whenever the tries to go to the toilet and she cannot produce any urine at all. However, the pain decreases a little between the periods of urgency. She rates the pain today as 7/10 on a scale from 1 to 10. She specifies that the pain has continued to worsen over the last two days and believes that she has a urinary tract infection because three years ago she presented with similar symptoms. The patient says the she wants treatment because it has not been easy for her to take care of her child when the pain peaks and she has to visit the toilet all the time.
Medications: None

Allergies: Penecillin

Medication Intolerances: Penicillin

Chronic Illnesses/Major Traumas: Chicken pox during childhood, asthma

Hospitalizations/Surgeries: Urinary tract infection at the age of 26

Family History: The mother suffered from lung cancer, hypertension, heart disease, and diabetes. The father is alive and diabetic. The patient’s uncle is alcoholic.
Social History: The patient smokes half a packet of cigarettes daily. She does not drink alcohol. She admits to have a short history of drug abuse but claims to have not used the narcotics for the past three months. She reports to be unemployed and currently stays at home with her child who is 2 years old. The patient lives with her boyfriend who is the father of her daughter. He works as a mechanic in a nearby motor vehicle company. The patient says that she does not do any regular exercise. Furthermore, she informs that she mostly cooks frozen food for her daughter or they eat out whenever she does not feel like cooking at home. She puts on a seat belt while traveling.
General: The patient denies fevers, chills, malaise, or headache. Cardiovascular: Denies chest pain, syncope, palpitations, or breathlessness.
Skin: Denies rashes, itching, acne, and other skin changes. Respiratory: Denies cough or even the production of sputum
Eyes: Denies blurred vision, itching, eye pain, or drainage.


Gastrointestinal: Denies nausea, constipation, vomiting, melena, indigestion, reflux, diarrhea, loss of appetite, or dysphagia. Lower abdominal pressure/pain
Ears: Denies ear pain, fullness, popping, drainage, or loss of hearing.


Genitourinary/Gynecological: Reports dysuria, polyuria, burning frequency, as well as incomplete bladder emptying without hematuria. Last monthly period was on July 14, 2017, lasting 5 days and with normal menstruation.
Nose/Mouth/Throat: Denies nose drainage, loss of smell, or sinus pressure. Also, denies sore throat, problem with swallowing, loss of taste, or bleeding gums. Reports tooth pain, gum pain, as well as difficulty with chewing. Musculoskeletal: Denies back pain, muscle stiffness, joint swelling, fracture, or osteoporosis.


Breast: Denies lumps, bumps, or any other changes.


Neurological: Denies orthopnea and syncope. Denies memory loss, weakness, imbalance, and arthritis.
Heme/Lymph/Endo: The patient is HIV negative, denies bruising, blood transfusion, swollen glands, or increased hunger. Psychiatric: Denies depression, anxiety, sleeping difficulties, suicidal ideation, or attempts.


Weight: 129 Lbl     BMI: 22.7 Temp: 98.5 BP: 76
Height: 62 inches Pulse: 102/60 Resp: 18
General Appearance: The patient is alert, awake, and responds appropriately.
Skin: She is afebrile; the skin is warm and dry.
HEENT: Head is normocephalic, atraumatic, and symmetricalNeck and trachea are midline and without lymphadenopathy. Her sclera and conjunctiva are clear, without discharge, and PERRLA. Ear is externally bilateral in shape and size while the skin tone is normal. Both ears have two piercings each but no masses or tragal tenderness. Patent external canals, without discharge, odor or foreign bodies bilaterally. Pink canals, tympanic membrane is gray, concave, light reflex, visible bony landmarks, and no ear cerumen. Nares are patent bilaterally while nasal septum is in midline. Turbinates are pink, moist, and without nasal discharge. Mucus membranes are pink, moist, without lesions while soft palate is intact. All teeth are present, 2 broken molars in the right upper and lower dentine. Evidence of decay, gum redness, but no bleeding or pus visualized. Her pharynx is pink while tonsils are 1+ without exudates, uvula is midline, sensitive gag reflex. Frontal and maxillary sinuses are non-tender to palpitation.
Cardiovascular: Normal S1 and S2 without any splits, rubs, skips, gallops, or murmurs.
Respiratory: Lungs are clear to auscultation, without crackles, wheezes or rhonchi.
Gastrointestinal: Abdomen is flat and symmetrical. No scars, dilated veins, rashes, peristalsis, lesions, or pulsations visible.
Breast: Free from masses, tenderness, no discharge, no dimpling, wrinkling, or discoloration.
Genitourinary: Free from masses, non-distended, skin color is consistent with general pigmentation, and no lesions
Musculoskeletal: Full ROM in every of the 4 patient’s extremities since she had the ability of moving about within the examination room.
Neurological: She speaks clearly and in good tune. Her posture is also erect with stable balance and normal gait.
Psychiatric: She is alert, oriented in place and time. She is dressed appropriately in blue jeans trousers, an aquamarine T-shirt, and light-blue slip-ons. The patient is able to maintain eye contact. Her speech is soft though can be heard clearly and distinguishably. The answers she gives to questions are appropriate.
Lab Tests

Urinalysis – not yet completed

Urine culture – Not done yet

Wet prep –Not done yet

Special Tests: Immersion culture media where a plastic rod will be coated with culture medium.
· Differential diagnoses:

a) Overactive bladder

b) Vaginitis

c) Urethral cancer

· Main Diagnosis

· Urinary tract infection: The patient presented with a complaint of urinary urgency, burning sensation with urination, lower abdominal cramping, and incomplete bladder emptying. Usually, urinary tract infection is known by an abnormal urge to urinate and to do it frequently, painful passage of urine, pain in the abdomen, and strongly smelling urine.

· Plan:

· Further testing: Testing will include dip sticks which are the most frequently used tools for diagnostic testing if there is evidence that a patient is suffering from the urinary tract infection. Multistix reagent strips are often used because they can detect nitrite, leucocyte esterase, protein as well as blood (Centers for Disease Control and Prevention, 2017).

· Medication: Take a single urine sample for culture before empiric antibiotic treatment commences (Revello & Gallo, 2013). There is no minimum number of antibiotic doses or therapy that defines a new antibiotic start. Include only antibiotics that are started while the patient is at the medical facility. Do not include antibiotic courses that were started by other healthcare providers prior to the visit or readmission back to the facility. Treating non-pregnant women who have UTI symptoms is with 3-day trimethoprim course and to those with acute UTI ciprofloxacin is given for a week.

· Education: Educate the care giver that unnecessary use of tests and antibiotic treatment can be minimized by developing simple decision rules, diagnostic guidelines, or other educational frameworks (Revello & Gallo, 2013). The antibiotics kill bacteria and alleviate the problems that the patient is undergoing currently.

· Nonmedication treatments: Cranberries help in preventing and treating urinary tract infections (UTIs). Cranberries decrease bacterial adherence to uroepithelial cells, thereby lowering the incidence of UTIs without adverse effects. Cranberries can also act as an adjunct to antibiotics for patients with repeated UTIs (Centers for Disease Control and Prevention, 2017). This intervention is expected to minimize the harmful effect of bacteria that may be in the patient’s genitourinary tract.

· Referrals: Recurrent UTI should be a reason for referring the patient to urologist (Centers for Disease Control and Prevention, 2017).

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