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Soap Note

Date: 06/25/2014, 27 Years old


Chief Complaint (CC): burning and pain with urination
History of present Illness (HPI): J. S. presents with unusually frequent urination, strong urge to
urinate, and pain, discomfort, and burning sensation during urination since last three days. Sates
that she voided 3 times in 1.5 hours at Costco yesterday. Her urine looks cloudy and has a foul
odor. Denies fever,nausea, vomiting, myalgia, flank pain, blood in urine, any vaginal discharge,
and, vaginal/vulvar irritation. Is sexually active, has same partner for last 4 years.
Past Medical History (PMH):
Childhood: Croup (1990). No chronic illness or conditions
Adult Illness: No major health problems except minor cold and fever.
OB/GYN: 1-1-0-0-1, with normal vaginal delivery. One living child. Menarche age 13.Last
menses 01/02/2014. Currently, sexually active. Is married and has same partner for 4 year. Last
GYN appointment in 09/22/2013. Was tested for STDs in the GYN office. Was negative for
Chlamydia, HIV, and Gonorrhea.
Surgeries: None
Psychiatric: None.
Medications: Is not taking any prescription, over-the-counter drugs, or vitamins or mineral
supplements.
Allergies: No known allergies. No seasonal allergy.
Immunization: Completed 3 doses of HPV vaccine in 2003, recent T-dap in 2011 (postpartum),
flu shot in 10/2013. All childhood immunizations are up to date. Never had any reactions to
vaccines in the past.
Family history:
Father: alive Hx of DM 2
Mother: deceased- Hx of HTN
Sister # 1: alive - HTN
Son : Alive
Review of System:

General. No generalized weakness or fatigue or recent changes in the weight.


Respiratory: No cough, shortness of breathing. No history of Asthma or seasonal allergy.
Cardiovascular: No cough, dyspnea on exertion, orthopnea, edema, and unusual fatigue. No
history of heart murmurs. No history of hypertension, rheumatic fever, and high
cholesterol.
Gastrointestinal: c/o of mild pain in the suprapubic area. Denies nausea , vomiting, and
abdominal pain.
GU: C/o of urinary frequency, urgency and dysuria since past three days. States that she had to
urinate at least 3 times in 1.5 hours at Costco yesterday. Denies any vaginal discharge, and
vaginal/vulvar irritation. States that she never had urinary tract infection before. Is sexually
active.
Objective:
Appearance: J.S. is a cooperative, alert, maintains eye contact, looks her stated age, well
groomed and appropriately dressed for the weather and the settings. No respiratory distress.
Appropriate affect.
Vital Signs: BP: 112/75, HR: 72, R: 16, T: 98.8,
Height: 63 inches

Weight: 120 lb. BMI: 21.3

Thorax and lungs: Breath sounds are clear and normal. No adventious breath sounds.
Cardiovascular: No murmur, gallops, rubs or extra heart sounds. No thrills, heaves or lifts. S1, S2
present.
Gastrointestinal: Abdomen soft and non-tender to touch, positive bowel sounds present.
GU: Suprapubic area tender to touch, No CVA tenderness.
Lab:
1. Dipstick urinalysis- positive for nitrite and leukocyte esterase positive
2. Urine Culture
Impression/Planning:
Diagnosis: Urinary tract infection, site not specified (ICD 9 599.0)

Differential Diagnosis: vaginitis(ICD-9 616.10), pyelonephritis (ICD-9 code 590.80),


overactive bladder (ICD 9 596.51).
The diagnosis of urinary tract infection was made based on the patients chief complain, history
of present illness, dipstick urinalysis result, as well as, physical examination. Clinical indicators
such as presence of suprapubic tenderness, dysuria, frequency, and urgency used to predict the
diagnosis of urinary tract infection (Patel, Lee, & Goldman, 2013). The diagnosis of vaginitis
was ruled out due to positive urine dipstick test, absence of symptoms such as vaginal discharge
and vaginal/vulvar irritation ( Patel et al., 2013). Similarly, the diagnosis of pyelonephritis was
ruled out because patient did not have symptoms such as fever, nausea, vomiting, myalgia, and
flank pain which is more consistent with the diagnosis of pyelonephritis (Domino, 2014). Even
though, symptoms such as urgency and frequency are consistent with the diagnosis of overactive
bladder, the positive result of dipstick urinalysis helped to rule out the diagnosis of overactive
bladder (Patel et al., 2013).
Plan: (According Patel et al., 2013; Intelihealth, 2014 )
1. Prescribe her Bactrim DS PO Q12 hours for 3 days.
2. Educate her to avoid spermicidal products because they decrease vaginal lactobacilli and
increase the risk of UTI.
3. Advise her to drink several glasses of water each day. Fluids discourage the growth of bacteria
by flushing out your urinary tract. Drinking cranberry juice may deter bacterial growth by
decreasing the ability of bacteria to stick to the urethra.
4. Advise her to wipe from front to back to prevent the spread of intestinal bacteria from the
rectum to the urinary tract. Educate her that women always should wipe toilet tissue from front
to the back after having a bowel movement.
5. Educate her that sexual activity is one of the strongest risk factors for UTI. Therefore, to
decrease the spread of bacteria during sex, advise her to urinate after sexual intercourse to flush
bacteria from your urethra.
6. Educate patient to complete full 3 days course of antibiotic.
Health Maintenance:
1. Advice patient to take 400 mcg folic supplement daily. Furthermore, educate her that folic acid
is very important for women of child bearing age to prevent birth defect even when she is not
planning for any pregnancy. Its needed during the first few weeks of pregnancy, often before a
woman knows shes pregnant (HHS, 2014).

2. Screening for cervical cancer: Educate patient that she should get her pap test every 3 years to
screen for cervical cancer. Her last pap test was in 09/2013, normal, so advise her to schedule her
next pap test in 09/ 2016.
3. Encourage her to get well-women visit once a year and her blood pressure checked at least one
every 2 years (HHS, 2014)
4. Educate her about the importance of flu shot and its side effect and advise her to get it every
year to prevent flu.
5. Educate patient to go for dental visit twice a year or every 6 months (Vorvick, 2012).
6. Advise patient to get tested for HIV at least once.
7. Educate her that based on her family history for heart disease and her risk for heart disease
(diabetes, smoking, high blood pressure, and obesity) she might need to get her blood cholesterol
checked once every 5 years (HHS, 2014).
8. Teach patient to get her eye examined every two years (Vorvick, 2012).

References
Domino, F.J. (2014). The 5-Minute clinical consult (22nd ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Intelihealth. (2014). urinary tract infections in women. Retrieved from
http://www.intelihealth.com/article/urinary-tract-infection-in-women
Patel, B.N, Lee,.U.J., & Goldman,H.B. (2013). Urinary tract infections in women. Retrieved
from htps://online.epocrates.com/noFrame/showPage.do?method=diseases
&MonographId=77&ActiveSectionId=11
U.S. department of health & human services (HHS). (2014). Healthfinder.gov. retrieved from
http://healthfinder.gov/myhealthfinder/Result.aspx?
age=30&gender=female&pregnant=f
alse
Vorvick, L.J. (2012). Health screening - women - age 18 39. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/007462.htm