You are going to write a pediatric SOAP note about atopic dermatitis. PT’s initials: C.J. is a 16 year old white male that goes to the pediatric clinic w

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Name: L. S

Age: 48 years old

Gender: Female

Chief Complaint (Reason for seeking health care)

I have been experiencing recurrent UTIs since I entered menopause, about 8 months ago. I have this burning and painful urination.

History of Present Illness (HPI)

A 48-year-old white female presents to the clinic with complaints of recurrent urinary tract infections (UTIs) since entering menopause approximately eight months ago. She reports experiencing episodes of painful and burning urination, increased urinary frequency, and an urgent need to urinate during these occurrences. The patient states that her current symptoms began a week ago and have gradually exacerbated. She reports having turbid urine with an unpleasant smell and sometimes experiencing trouble starting to urinate. She also notes lower abdominal pain and discomfort that is most noticeable when her bladder feels full and subsides between voiding episodes. She states her pain as 4/10, but denies fever, chills, nausea, vomiting, back or flank pain, hematuria, vaginal redness and discharge. She is sexually active and in a monogamous relationship with her husband of 20 years. She expresses anxiety about the recurrency of UTIs since menopause, about 3 episodes in eight months, and seeks guidance on preventing further occurrences.

Allergies

The patient has no known allergies to medications or foods.

Review of Systems (ROS)

General: The patient reports no general weakness, chills, fever, or unexplained weight changes.

HEENT: No issues with vision changes, blurriness, or double vision. No hearing changes, problems, congestion, or sore throat.

Neck: No swelling lymph nodes or pain.

Lungs: No cough, shortness of breath, or adventitious sounds. No history of asthma and allergies.

Cardio: No chest pain, swelling, palpitations, tachycardia, or breathing difficulties.

Breast: No pain, tenderness, nipple deviation or discharge.

GI: Reports no pain in the abdomen. No nausea, vomiting, diarrhea and constipation.

M/F genital: No lesions, discharge, reports vaginal dryness.

GU: Reports sudden urge to urinate, and pain during urination for a week. No vaginal discharge or redness reports vaginal dryness. History of recurrent UTIs, 3 episodes in the last 8 months after entering menopause. Sexually active and married. No history of STIs, reports occasional painful intercourse.

Neuro: No memory changes, no dizziness, no numbness, no loss of balance.

Musculo: No back pain, muscle pain, joint swelling, or pain.

Activity: Full ROM goes to the gym 4 times a week.

Psychosocial: No mood changes, reports irritability because of UTI symptoms.

Derm: No hematomas, lesions or rashes.

Nutrition: Reports eating 4 meals per day and a diet low in carbs.

Sleep/Rest: Reports waking up in the middle of the night with hot flashes.

LMP: Post-menopausal

STI Hx: Denies STIs history.

Vital Signs

Temperature: 37.2 Celsius, pulse: 70, respiration: 18; oxygen saturation: 98% RA; blood pressure: 117/78; weight: 59Kg; height: 63 inches; BMI: 21.3

Labs

A dipstick urinalysis reveals the presence of nitrites and leukocyte esterase.

Urinalysis indicates pyuria with an uncountable leukocytes, along with erythrocytes and E.Coli. CBC is normal, except for a WBC elevated 12000. FSH 89.6mIU/mL, LH 34.2IU/L, Estrogen 11.1pg/mL, Progesterone 0.15ng/mL

Medications

No medications. Takes vitamin D3, K, C and Omega6 supplements daily.

Past Medical History

The patient had no major health concerns during childhood or adulthood, aside from occasional minor fevers and colds. There is no history of chronic diseases.

Past Surgical History

1 C-section in July 0f 2005.

Family History

The patient's father has diabetes juveniles, and the mother is hypertensive along with a history of urinary tract infections following menopause. The older brother also has high blood pressure. There is no cancer in the family history.

Social History

The patient resides with her husband and child. She is employed as an accountant at a local taxes company. She occasionally consumes alcohol (2 glasses of wine on the weekend) and denies using tobacco or illegal drugs.

Health Maintenance/ Screenings

Colonoscopy: 01/2024, normal.

Mammogram;05/2024, normal.

Pap Smear: 05/2024, normal.

Physical Examination

General: The patient is a 48-year-old white female with no signs of acute distress.

HEENT: No dry eyes, runny nose, sore throat, headache, or dizziness. (PERRLA), tympanic membranes are intact and pearly gray, nasal mucosa is pink and moist, oral mucosa is pink, and the neck is non-tender with a midline trachea.

Neck:

Lungs: Sounds clear, no adventitious sounds noted, no tachypnea.

Cardio: S1, S2 sounds noted, no gallops, trills or palpitations noted. Pulses brachial bilaterally 2+

Breast: No nodules felt upon palpation, no nipple deviation or discoloration, no discharges noted.

GI: No pain, tenderness, nausea, vomiting, or appetite changes. Normal activity in all 4 quadrants.

M/F genital: Vaginal mucosa thin and pale; signs of atrophy.

GU: Bladder is not distended, no costovertebral angle tenderness, abdomen is flat and soft. Upon palpation, pt states suprapubic pain. Urinalysis shows positive nitrites and red blood cells.

Neuro: Alerted and oriented, good balance, no signs of dizziness, normal grip, press well against resistance,

Musculo: Full ROM, no signs of joint distress.

Activity: Full ROM on upper and lower limbs

Psychosocial: Cooperative but concerned about prognosis.

Derm: Skin is dry and intact, no hematomas, lesions, blisters, discoloration.

Diagnosis

Primary: Recurrent urinary tract infection (N39.0).

Differential Diagnosis

Atrophic vaginitis (N95.2): Atrophic vaginitis, or genitourinary syndrome of menopause (GSM), is a condition marked by the thinning, dryness, and inflammation of the vaginal tissues, typically resulting from lowered estrogen levels, especially following menopause. The decline in estrogen results in reduced vaginal elasticity, decreased lubrication, and a change in the vaginal pH, making the area more susceptible to irritation, infections, and discomfort during intercourse. Symptoms of atrophic vaginitis include vaginal dryness, itching, burning, dyspareunia (pain during sex), and recurrent urinary tract infections (ACOG, 2023).

Interstitial cystitis (N30.10): Interstitial cystitis (IC), also known as bladder pain syndrome, is a chronic condition characterized by persistent bladder pain, pressure, or discomfort accompanied by urinary symptoms such as urgency and frequency in the absence of a urinary tract infection or other identifiable causes. The exact etiology of IC is unclear, but it is believed to involve a combination of factors, including defects in the bladder lining, immune dysregulation, and nerve hypersensitivity. Patients with IC often report flare-ups of symptoms triggered by certain foods, beverages, or stress (Clemens et al., 2019).

Urethral syndrome (N34.2): Urethral syndrome is a condition characterized by urinary symptoms such as dysuria, frequency, urgency, and suprapubic discomfort in the absence of a detectable infection or other structural abnormalities. It is more common in women and often overlaps with other conditions, such as interstitial cystitis and overactive bladder. The etiology of urethral syndrome is multifactorial, with contributing factors including irritation or inflammation of the urethra, hormonal changes, pelvic floor dysfunction, and psychosocial stressors. Estrogen therapy may be beneficial in postmenopausal women experiencing urethral syndrome due to urogenital atrophy (Dmochowski & Gomelsky, 2019).

ICD 10 Coding

N39.0: Urinary tract infection.

N95.2: Atrophic vaginitis.

N34.2: Urethral syndrome.

Pharmacologic treatment plan

Nitrofurantoin 100 mg, PO, BID for 7 days. Effective against E. coli with minimal resistance (Gupta et al., 2019).

Topical estrogen cream (Estradiol 0.01%), apply 1g intravaginally nightly for 2 weeks, then twice weekly. Improves vaginal mucosal health and reduces recurrence of UTIs (Moore et al., 2022).

Diagnostic/Lab Testing

Repeat urine culture 7-10 days after completing antibiotics to confirm clearance.

Ultrasound of kidneys and bladder if recurrence persists to assess for structural abnormalities.

Education

Educate about proper hydration (2-3 liters daily) to dilute urine and flush bacteria (Johnson & Johnston, 2020).

Proper perineal hygiene: Wipe front to back to reduce bacterial contamination.

Post-coital urination to reduce UTI risk.

Symptoms to monitor for recurrent infection, including fever, back pain, or hematuria.

Anticipatory Guidance

Prophylactic Measures: Preventive strategies include increasing fluid intake, urinating after sexual intercourse, and avoiding potential irritants such as douches and scented products. Prophylactic antibiotic regimens or non-antibiotic options, such as vaginal estrogen therapy in postmenopausal women, can help reduce the frequency of infections (Gupta et al., 2017).

Behavioral Interventions: Educate patients on the importance of adequate hydration and bladder emptying habits. Drinking sufficient water can dilute the urine and flush out bacteria, reducing the risk of colonization. Patients should also avoid delaying urination and ensure proper perineal hygiene, wiping from front to back to minimize bacterial migration from the rectum (Vahlensieck et al., 2020).

Dietary and Lifestyle Modifications: Emerging evidence supports the role of dietary supplements, such as cranberry products, in reducing UTI recurrence by preventing bacterial adherence to the urinary tract lining. Probiotics containing Lactobacillus may also restore healthy vaginal flora and provide additional protection (Gupta et al., 2017).

Patient Education: Patients should be informed about recognizing early signs of UTI (e.g., dysuria, frequency, and urgency) and the importance of seeking timely medical attention. Stress the potential consequences of untreated infections, such as pyelonephritis, which could lead to renal damage.

Follow-up and Monitoring: Regular follow-ups are critical, especially for individuals at higher risk (e.g., diabetics, immunocompromised patients). Periodic urinalysis or urine culture may be warranted to monitor for asymptomatic bacteriuria, which is typically not treated unless in pregnancy or before certain urological procedures (Hooton et al., 2018).

Follow up plan

Schedule a follow-up appointment in two weeks to discuss the urine culture results and evaluate symptom progress. If recurrent infections continue despite treatment, consider referring the patient to a urologist.

Prescription

See Below (scroll down)

References

American College of Obstetricians and Gynecologists (ACOG). (2023). UTIs after menopause: Why they’re common and what to do about them. Retrieved from ACOG.org

Gupta, K., et al. (2019). Management of recurrent urinary tract infections in women. New England Journal of Medicine, 382(11), 1020-1029.

Raz, R., & Stamm, W. E. (2019). Vaginal estrogen for the prevention of recurrent urinary tract infections. Clinical Infectious Diseases, 30(2), 203-208.

Johnson, E. K., & Johnston, B. (2020). Recurrent urinary tract infections: An evidence-based approach. American Family Physician, 101(9), 560-569.

Nicolle, L. E. (2021). Recurrent urinary tract infections in postmenopausal women: Strategies for prevention. Journal of Urology, 206(2), 280-285.

Clemens, J. Q., Erickson, D. R., & Vasanwala, F. F. (2019). Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis. UpToDate

Dmochowski, R., & Gomelsky, A. (2019). Female urethral disorders: Diagnosis and treatment. UpToDate

Gupta, K., Trautner, B. W., & Nicolle, L. E. (2017). Urinary tract infection in adults. UpToDate.

Hooton, T. M., Vecchio, M., Iroz, A., Tack, I., & Dornic, Q. (2018). Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: A randomized clinical trial. JAMA Internal Medicine, 178(11), 1509–1515.

Vahlensieck, W., Perepanova, T., Schmelz, H. U., et al. (2020). Prevention of recurrent urinary tract infections: Focus on a phytoextract-based medical device. Research and Reports in Urology, 12, 239–250.

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)___L. S. Age 48-years-old

Date: _11/21/2024

RX _Nitrofurantoin: 100 mg capsule, take one capsule by mouth twice daily for 7 days. _______________

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