Patient is a 21 y/o male with GERD without esophagitis, who came to discuss test results, abdominal US was within normal limits, he indicates was seen by G

Soap Note #4 : Urinary tract infection uncomplicated

Valeria Klimack

Miami Regional University

6400C Clinical for Role Development in Family Practice: Clinical Integration

09/26/2024

Denis Nunez-Sanchez APRN./Coral Reef Medical Groul Old Dixie Highway

Professor: Dr. Waldo Garcia

SOAP Note # and Diagnosis

PATIENT INFORMATION

Name: C.L

Age: 33 years

Gender at Birth: Female

Gender Identity: Female

Source: Patient

SUBJECTIVE DATA

Chief Complaint: "It burns when I pee and I feel like I have to go all the time but not much comes out”.

HPI: History of Present Illness (HPI):

Patient is a very kind 33 y/o female who came for consultation today complaining of burning sensation when urinating which has been getting worse over the past days , she also reports frequent and urgent urinating sensation with small volumes along with pelvic pressure along with  a recurring feeling of her bladder filling up. Patient denies fever, discharge and other associated symptoms, she has a consistent partner, engages in sexual activity, and uses condoms as contraceptive method. She has never been known to have a STI.

Allergies: No known drug allergies.

Current Medications:

· Multivitamin, 1 tablet daily

· Ibuprofen, 200 mg as needed for pain (last dose taken 8 hours ago)

Past Medical History:

· Recurrent urinary tract infections

· Seasonal allergies

Immunizations: Up to date, including annual flu shot.

Preventive Care: Last Pap smear and pelvic exam conducted 6 months ago, both normal.

Last Wellness Exam: 6 months ago, no abnormalities reported.

Surgical History: Wisdom teeth at 23 y/o

Family History:

· Mother: Hypertension, Type 2 Diabetes

· Father: Hyperlipidemia

· Siblings: 2 sisters, No known chronic illnesses

Social History:

· Occupation: Administrative assistant, full-time

· Living situation: Lives alone in an apartment

· Smoking: Never smoked

· Alcohol: Drinks socially, about 2-3 glasses of wine per week

· Exercise: Walks 3-4 times a week, exercises at the gym 3 times a week

· Sexual activity: Active with one stable partner, uses condoms

Sexual Orientation: Heterosexual

Nutrition History: Patient reports diet rich in fruits, vegetables and low in carbs, eats meat 3 times per week, and salmon at least once per week, this is a balanced diet with adequate fluid intake, she denies changes in diet.

ROS:

· Constitutional: She denies chills, fever, or appreciable loss of weight. reports overall exhaustion especially since symptoms started.

· HEENT: Eyes: Denies changes in vision, eye pain or drainage Ears: Denies hearing loss, discharge, pain. Nose: Denies nasal congestion, postnasal drip. Mouth/Throat: denies sore throat, or oral ulcers.

· Cardiovascular: Patient denies chest pain, palpitations, or edema.

· Respiratory: Denies shortness of breath, cough, or any other respiratory symptoms

· Gastrointestinal: Reports mild lower abdominal discomfort, described as pelvic pressure, nausea, vomiting, or changes in bowel movements.

· Genitourinary: Reports increasing urgency, frequency, and dysuria, denies vaginal discharge nor hematuria. Denies history of pregnancies, Reports single sexual partner, engages in sexual activity, and uses condoms as contraceptive method She has never been known to have a STD. Reports LMP 3 weeks ago,

· Musculoskeletal: Denies joint pain, stiffness, or muscle aches.

· Integumentary (Skin, Hair, Nails): Patient denies rashes, itching, or hair loss.

· Hematologic/Lymphatic: Denies bruising, bleeding, or swollen lymph nodes.

· Endocrine: Denies heat or cold intolerance, no polyuria, polydipsia, or unexplained weight changes.

· Immunologic/Allergic: No known allergies to medications or environmental factors.

· Neurological: Patient denies headaches, seizurs, dizziness, or loss of consciousness.

· Psychiatric: Reports feeling anxious due to discomfort but denies depression.

OBJECTIVE DATA

Vital Signs:

· Weight: 150 lbs Height: 5’6” BMI: 24.2 (Normal)

· Blood Pressure (BP): 118/76 mmHg

· Heart Rate (HR): 72 bpm

· Respiratory Rate (RR): 16 breaths per minute

· Temperature: 98.6°F

· Pain: 3/10 (burning sensation during urination)

Physical Examination:

· General: Alert and oriented, no acute distress.

· Head: No visible evidence of trauma, alterations no presence of masses. Eyes: Symmetric, Bilateral Pupils equal, rounded and reactive to light and accommodation . No evidence of conjunctival pallor, or drainage. Ears: Symmetrical, no evidence of masses, Otoscopy: EEC with cerumen, Tympanic membrane mobile, gray with light reflex present, no evidence of effusion, or bulging. Nose: Symmetric, No evidence of nasal flaring, hypertrophy of turbinates or discharge, no masses. Throat: Oral mucosa moist and pink, no lesions. No evidence of erythema or exudate. Neck: Mobile, No presence of lymphadenopathy or scars.

· Cardiovascular: Heart sounds normal, regular rate and rhythm. No murmurs, gallops, or rubs.

· Respiratory: Chest expansible, clear to auscultation bilaterally, no evidence of added respiratory sounds.

· Gastrointestinal: Soft, non-tender abdomen with mild suprapubic discomfort upon palpation. Bowel sounds present in all quadrants.

· Genitourinary: Mild suprapubic tenderness, no costovertebral angle (CVA) tenderness. External genitals no evaluated.

· Musculoskeletal: Full range of motion in all extremities, no joint tenderness or swelling.

· Integumentary: Skin warm and dry, no rashes or lesions.

· Neurological: Alert and oriented to person, place, time, and situation. Cranial nerves II-XII evaluated and intact; no deficits noted. Motor Strength: 5/5 in both upper and lower extremities. Deep tendon reflexes 2+ Sensory Function: Intact to light touch, pinprick, and proprioception. Balance appropiate; gait is steady when walking. Coordination: No ataxia; normal finger-to-nose and heel-to-shin tests

· Psychiatric: Anxious but cooperative, appropriate mood and affect.

ASSESSMENT

C.L , a 33-year-old woman, came to consultation complaining of dysuria, increased urine frequency, urgency, and moderate suprapubic pain, urine sample was taken, dispstick test was performed at the office and reported presence of nitrites and leukocytes , this along with symptoms presented are indicating an uncomplicated UTI. There were no positive findings on the physical examination. Her history of recurrent UTIs and lack of systemic symptoms like fever or chills corroborate this diagnosis. The quick start of symptoms, absence of vaginal discharge or itching, continuous condom usage, and steady sexual relationship make interstitial cystitis, vaginitis, and STIs less probable. For three days, Trimethoprim-Sulfamethoxazole is prescribed, UTI education is provided, and symptom remission is monitored.

Main Diagnosis: Uncomplicated Urinary Tract Infection (UTI) ICD-10: N39.0

This diagnosis is supported by the patient having symptoms of dysuria, urinary frequency, and urgency, along with mild suprapubic discomfort in conjunction with her history of recurrent UTIs (Bono et al., 2023). Without fever, chills, or flank/back pain, complicated UTI or pyelonephritis is less likely.

Differential Diagnoses

1. Interstitial Cystitis (ICD-10: N30.10)

IC is a chronic condition that mainly manifests with symptoms of bladder pain, discomfort, or pressure-usually accompanied by urgency and frequency of urination. Unlike a typical urinary tract infection, IC does not result from a bacterial infection; neither are standard UTI treatments effective. The exact cause of IC is unknown, but it is presumed to involve a defect in the lining of the bladder, immune responses, or problems with the nerves (Lim & O’Rourke, 2021). In this case, IC could be considered because the patient was describing discomfort to her bladder and had symptoms related to urination. In this scenario, though, IC is less likely because the onset of the patient's symptoms is more acute in nature and it more characteristically presents with a UTI. History of UTIs and no prior chronic pain to the bladder makes IC less likely.

2. Vaginitis (ICD-10: N76.0)

Vaginitis is an inflammation or infection of the vagina usually caused by bacteria, yeast, or other organisms. Vaginitis can cause symptoms that may include discharge in the vagina, itching, irritation, and pain on urination (Sheppard, 2020). The closeness of the vagina and the urinary tract may account for the fact that symptoms of dysuria and frequency can present similarly and thus may be mistaken for a UTI. It would thus also be in the differential diagnosis-as some of the symptoms of urinary abnormalities can present like those of vaginitis. However, in the case of vaginitis, it is not likely since the patient has no complaints of vaginal discharge, itching, or irritation-which are usually quite prominent in vaginitis. Further, she shows symptoms more related to discomfort associated with urination-a UTI.

3. Sexually Transmitted Infection (STI) ICD-10: A60.9)

Many sexually transmitted infections, including chlamydia and herpes, also have symptoms of dysuria, frequency, and pelvic discomfort. STIs should be a consideration in sexually active patients, especially if the history is one of unprotected sex and multiple partners. In this case, an STI is considered while noting the overlap in urinary symptoms; however, this patient has a stable sexual relationship and uses condoms consistently (Garcia & Wray, 2023). Also, the absence of potential symptoms from STIs, such as sores on the genitals, abnormal discharge of fluids from the vagina, or new sexual partners, reduces the chances that the patient's current symptoms originate from an STI.

PLAN

Diagnostics tests:

-Dipstick test was performed at office, showed presence of nitrites and leukocytes.

-Urinalysis + culture ordered, sample was sent to laboratory for processing.

Pharmacologic Treatment

Antibiotic: The patient should be prescribed Trimethoprim-Sulfamethoxazole (Bactrim), 160 mg/800 mg, 1 tablet bid × 3 days, in line with current guidelines pertaining to uncomplicated UTI.

Pain Relief: Ibuprofen 200 mg, continue as necessary for pain. Instruct not to exceed more than 1200 mg in a 24-hour period.

Non-Pharmacologic Treatment:

Increase fluid intake to help flush out the urinary tract. Advice regarding correct hygiene with regard to wiping correctly from the front to back and urination in case of sexual intercourse. Recommend wearing cotton underwear and avoiding tight-fitting clothes.

Patient Education:

Educate regarding the signs of an infection getting worse, such as fever, chills, or back pain that would require immediate medical attention.

Discuss why the full course of antibiotics should be taken, even when symptoms get better before the medication is gone.

Follow-up and Monitoring:

Follow-up in one week, re-evaluating symptoms and confirming the resolution of the UTI. If symptoms persist or worsen, treatment will be adjusted, we will evaluate culture results and will adjust antibiotics if needed

Referral: No immediate referral is required, but if the problem of recurrent UTIs continues, then consider referring to urology for further evaluation.

References

Bono, M. J., Reygaert, W. C., & Leslie, S. W. (2023, November 13).  Urinary tract infection. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470195/

Garcia, M. R., & Wray, A. A. (2023). Sexually Transmitted Infections. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560808/

Lim, Y., & O’Rourke, S. (2021). Interstitial Cystitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570588/

Sheppard, C. (2020). Treatment of vulvovaginitis. Australian Prescriber, 43(6), 195–199. https://doi.org/10.18773/austprescr.2020.055

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