Urinary Tract Infection Soap Note

Allergies:  No known food and drug allergy

Medication Intolerances:She has no known medical intolerances

Chronic Illnesses/Major traumas: She was recently diagnosed with hypertension, which is under control via the use of medication and lifestyle modification.

Hospitalizations/Surgeries

No history of hospitalizations and surgeries

Patient has a significant family history of kidney failure (mother, 54-year-old) and prostate cancer (father, 58-year-old).

She is a graduate working in a bank, married to one husband and has two children. Her dietary habits include eating fast foods during lunch times and occasionally drinking of alcohol. However, she denies smoking tobacco, and does not value physical exercises.

Patient reports experiencing fever but denies having changes in weight, fatigue, chills, night sweats, or energy level

She denies having cardiovascular symptoms such as chest pain, palpitations and edema.

She denies having rashes, bruising, bleeding or skin discolorations as well as any changes in lesions or moles.

She denies cough, wheezing, hemoptysis, dyspnea, or history of pneumonia or TB

She denies using corrective lenses, blurring and visual changes of any kind.

C.S mentions that she has abdominal flank pains, nausea and vomiting. Patient, however, denies diarrhea, history of constipation, hepatitis, hemorrhoids, presence of black tarry stools or watery stools or eating disorders.

She has no ear pain, hearing loss, ringing in ears and discharge

She reports urinary frequency but denies having urgency, burning, change in color of urine and history of STDs.

She denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness and throat pain

She denies experiencing back pain, joint swelling, stiffness or pain, and fracture history

C.S reports that she does SBE monthly and has not noticed any lumps, bumps, or changes to the breast.

She denies experiencing syncope, seizures, transient paralysis, weakness, paresthesias or black out spells

She denies having bruises, blood transfusion history, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance.

She has no psychiatric history.

C.S is an adult African-American female who is in no acute distress. She is alert and well oriented to time, place and person, as well as answers questions appropriately. She is cooperative during the interview.

She has normal skin color, warm, clean, and intact with no rashes or lesions.

Her head is of normal shape with no abnormal findings, lesions noted.

Eyes: PERRLA. EOMs are intact. She has no conjunctival or scleral injection.

Ears: Canals are patent. Both TMs are pearly gray with positive light reflex and landmarks easily seen.

Nose: Nasal mucosa is pink in color, has normal turbinates and devoid of septal deviation.

Neck: Supple. Full ROM. Has no cervical lymphadenopathy as well as occipital nodes. She is of thyromegaly or nodules. The oral mucosa is pink and moist. Her pharynx is non-erythematous and without exudate. The teeth are in good shape and repair.

S1 and S2 are present with regular rate and rhythm. Extra sounds, clicks, rubs or murmurs are absent. Capillary refill is normal since it occurs in 2 seconds. Pulses 3+ are throughout.  She presents devoid of edema.

She has a symmetric chest wall.  Respirations are regular and easy. Lungs are clear to auscultation bilaterally.

Abdominal girth is normal. Bowel sounds are active in all 4 quadrants. Abdomen is soft and non-tender upon palpation.  She has no masses and hepatosplenomegaly.

She has no breast lumps and tenderness. Her breasts are devoid of discharge, palpable lesions, dimpling, wrinkling or discoloration of the skin.

She has a right sided CVA tendernessand a non-distended bladder. Genitals remain unexamined.

C.S has a full ROM seen in all 4 extremities as patient is able to move about the exam room.

Speech is clear and of good tone. Posture is erect, her balance is stable and gait is normal.

Alert and well oriented. She is dressed appropriately with clean clothes. She maintains eye contact throughout the interview. Her speech is soft, clear and of normal rate and cadence. Her answers to questions are appropriate.

Urinalysis— WBC +++

Urine culture and sensitivity—pending

• • Acute Pyelonephritis (N10): An upper bacteria-mediated UTI that affects the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Appropriateness of this diagnosis is highlighted by the subjective and objective data obtained from C.S. She presents with fever, urinary frequency, flank pain and CVA tenderness, which are classic signs and symptoms of this diagnosis (Winkelman, Workman, &Ignatavicius, 2013).
  • Acute pancreatitis (K85.9): Of significance to this condition are its manifestations like abdominal pain, nausea, vomiting, diarrhea, anorexia, and fever. On physical assessment, individuals present with either Cullen’s or Grey-Turner’s sign (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Given the absence of classic manifestations of acute pancreatitis, it is beyond doubt that C.S’s diagnosis is not this one.
  • Nephrolithiasis (N20.0): Central to this condition are manifestations such as hematuria, pain radiating to anteriorly and downwards, tenderness, nausea vomiting, diarrhea and abdominal discomfort (Copstead-Kirkhorn, &Banasik, 2014). Given the mismatch of these manifestations with C.S presentation, it is apparent that she is not a victim of nephrolithiasis.

Final Diagnosis

• • Acute Pyelonephritis (N10): An upper bacteria-mediated UTI that affects the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Appropriateness of this diagnosis is highlighted by the subjective and objective data obtained from C.S. She presents with fever, urinary frequency, flank pain and CVA tenderness, which are classic signs and symptoms of this diagnosis (Winkelman, Workman, &Ignatavicius, 2013).

Medication: Ciprofloxacin 250mg BID for the UTI

Education: Reinforce on the need for consuming adequate fluids, regular emptying of the bladder, and adherence to recommended perineal hygiene for the prevention of recurrence (Buttaro, et al., 2013).

Nonmedication treatments: Adopting good voiding habits such as voiding immediately after sexual intercourse, and adherence to good perineal hygiene (Copstead-Kirkhorn, &Banasik, 2014).

Follow-up: Patient to come after two weeks  for follow-up to assess the clearance of the infection (Hinkle, Brunner, Cheever, &Suddarth, 2014).