Demographic Information:

Initials of Patient: AA

Patient Age: 20

Patient Gender: Female

Patient Ethnicity: African American

Initials of Provider: AK

Clinical Setting: ER

Insurance: Private___; Medicare____; Medicaid____

Patient Status: ____New ____Established

Chief Complaint (CC): “It hurts when I pee”

History of Present Illness (HPI): AA presents with a 2-day history of frequent urination,

urgency, a burning pain on urination. She states that in last hour since she checked herself in, she

had to void 2 times. The urine is cloudy looking with a foul smell. AA denies fever, flank pain,

myalgia, nausea and vomiting. She also denies any vaginal itching, vaginal discharge or blood in

urine. AA is sexually active with same male partner since last 6 months.

Pain History if Indicated:

Location: GU

Quality: Dull

Severity: 10/10 on a pain scale of 1 - 10

Duration: Only during urination

Timing; Upon urination

Context: Pain on urination

Relieving Factors: End of urination

Exacerbating Factors: Beginning and during urination

Associated Symptoms - None

Meaning of the Pain – Interferes with quality of life

Review of Systems (ROS):

Constitutional: No generalized weakness, weight gain/loss, fatigue, chills or sweating.

Respiratory: No cough, no shortness of breath, asthma or any seasonal allergies.

Cardiac: No cough, no dyspnea on exertion, orthopnea, generalized edema, and unusual fatigue.

No palpitation, no hypertension, history of rheumatic fever and no high cholesterol.

GI: Mild pain in suprapubic area on palpation, no other abdominal pain, stomach soft and no

guarding. Denies nausea and vomiting.

GU: A 2-day history of increased urinary frequency, urinary urgency, and dysuria. She states

that in last hour since she checked herself in, she had to void 2 times. She denies any vaginal

itching, and vaginal discharge. She has had a similar episode 2 months ago and two episodes last

year all were treated with antibiotics.

GYN (female): Nullipara. Menarche at 13 and LMP (Last Menstruation Period) was 2 days ago.

She is single and has same partner since last 6 months. She is sexually active, and her last
Gynecology visit was 2 years ago. 8 months ago, when she has had a same episode, she was

referred to health clinic where she was tested and was found to be negative for STDs (Sexually

Transmitted Diseases).

Allergic/Immunologic: None

Past history (include dates):

PMH: PT denies any history of any chronic illnesses, including but not limited to hypertension,

CVD, and diabetes. PT has had minor cold and fever in the past.

PSH: Denies alcohol, tobacco and drug use. Sexually active with one partner of 1 year and says

always use condoms.

Obstetrical History: None

Hospitalizations: None

Medications: No regular medication prescribed, occasional OTC painkillers for regular

headaches or body aches. Denies taking any OTC medications, vitamins or minerals.

Allergies: Medications, Foods, Other Allergens: NKA (No known allergies) & NKDA (No

known drug allergies)

Immunizations: Childhood immunization UTD.

OBJECTIVE DATA

Vital Signs: BP 115/78, Pulse: 73, RR: 18, T: 98.7

Oxygen Saturation: 100% at room air

Ht: 5’7
Wt: 130lb

BMI: 20.5

Constitutional:

General: AA appears her stated age and is dressed appropriately for weather and setting. She is

AA&OX3, cooperative, maintains good eye contact. Affect is appropriate and she shows no

signs of any respiratory distress.

Physical Examination:

Respiratory: Bilateral lung auscultation shows no adventitious sounds. Lungs clear and

respiration is normal.

Cardiac: S1 and S2 presents and audible. No murmurs, gallops, palpitations or extra heart

sounds. No thrills, heaves or lift noted.

GI: No abnormality in contours. Bowel sounds present. Stomach soft and non-tender

GU: Tenderness on palpation of suprapubic area. No pain on costovertebral angle percussion.

Laboratory Data Already Ordered and Available for Review: Dipstick Urinalysis is positive

for leukocytes esterase and positive nitrites

Diagnostic Procedures/Data Already Ordered and Available for Review (If not done will go

in plan): Urine culture ordered.

ASSESSMENT

1) Main Diagnosis/Health Problem: Acute cystitis without hematuria– ICD 10 – N30.0

2) Differential Diagnoses Related to Each Main Diagnosis/Health Problem:

Pyelonephritis (ICD – N10.0), and Vaginitis (ICD 10 – N76.0)

3) Additional Health Problem/Dx: None

PLAN

Empirical treatment started with an antibiotic and Pyridium for dysuria (only for 2 days). Patient

will be educated on disease process, prevention and medical treatment. Patient will be provided

with complementary treatment options. Patient will be verbalized understanding. Patient will be

advised to follow-up with her Primary Care Physician (PCP). Patient will be educated on signs

and symptoms that requires her to seek immediate medical help. If urine culture requires

treatment change or any other notifications, patient will be notified promptly to either return to

ER or to have the report forwarded to her PCP.

Additional Laboratory Tests or Diagnostic Data Needed – Urine culture done. If urine

culture requires treatment change or any other notifications, patient will be notified promptly to

either return to ER (Emergency room) or to have the report forwarded to her PCP.

Pharmacologic Management:

Drug, dose, route, frequency, Disp amount

SIG (write like a prescription)

Nitrofurantoin Monohydrate/Macrocrystals (Macrobid) 100mg 1 Tab PO BID for 5 days

Dispense: 10 Tab

Pyridium 200mg 1 Tab PO TID for 2 days

Dispense: 6 Tab
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.

1 - Drink eight 8-ounce glasses of water per day; this helps in flushing out the bacteria which is

the cause of your infection (Dunphy, Winland-Brown, Porter, & Thomas, 2019)

2 – Bacteria can adhere to the bladder internal lining, you can take cranberry supplement and

drink cranberry juice to decrease the bacteria’s ability to adhere (Dunphy, Winland-Brown,

Porter, & Thomas, 2019)

Complementary Therapies: i.e. relaxation techniques, imagery, music or pet therapy, exercise,

massage - None

Health Education:

1 – Nitrofurantoin is an antibiotic that is given to treat the infection that is causing you the

symptoms. It is important that you take one (1) pill two (2) times a day, till all pills are gone.

Even if you start feeling better it is important that you finished all the pills so that your treatment

is completed

2 – Pyridium is a tablet for pain that happens when you pee. Take one (1) tablet three (3) times a

day for two (2) days in a row.

3 – If you develop a high fever 101F return to the hospital.

4 – If you develop any respiratory problems or start seeing blood in urine please return to the

hospital.

5 – Nylon undergarments and “thongs” help build moisture that aid bacterial infection, instead

wear cotton underclothes (Dunphy, Winland-Brown, Porter, & Thomas, 2019).

6 – Harsh soap and feminine hygiene products can irritate urethra, allowing bacterial invasion,

avoid them (Dunphy, Winland-Brown, Porter, & Thomas, 2019).

7 – Condoms provide a barrier to infection (Dunphy, Winland-Brown, Porter, & Thomas, 2019)

8 – Frequent peeing helps reduce urine stasis in bladder decreasing bacterial growth (Dunphy,

Winland-Brown, Porter, & Thomas, 2019).

9 – Tub baths and bubble baths chemicals can irritate urethra, instead employ shower (Dunphy,

Winland-Brown, Porter, & Thomas, 2019).

Referrals: None

Follow-up Appointment: With her PCP.

Billing Level:

Patient Status: New (99203)

Level of history: Expanded-Problem focused – CC, HPI and ROS done which makes this an

extended-problem focused history. This was done because patient stated she has had same

infection 8 months ago, therefore it was necessary to rule out recurrent or complicated UTI.

Level of physical (exam): Expanded-Problem focused - ROS of system done to eliminate

differential diagnosis. 4 system reviewed which falls between the definition of extended-focused

exam comprising of 2 – 9 systems.

Level of Medical decision making: Low Complexity: This is an uncomplicated Cystitis as

evident by absence of generalized symptoms and localized symptoms of urgency, frequency and

dysuria.
ANALYSIS of SOAP NOTE

INSTRUCTIONS: Please follow exactly the questions as outlined below

1. Subjective: Compare and contrast subjective data section with literature and discuss

subjective data as it pertains to primary diagnoses and possible differential diagnosis.

Urinary Tract Infection (UTI) diagnosis was made based on chief complain i.e., dysuria and

subjective symptoms mentioned by the patient along with HPI. Clinical manifestations of

dysuria, urinary frequency and urgency all points toward a possible diagnosis of UTI (Hooton &

Gupta, 2019a). Vaginitis clinical presentation usually consists of a complain of malodorous

discharge, vaginal pain or soreness, pelvic discomfort and some signs of inflammation (Paladine

& Desai, 2018). Acute Pyelonephritis clinical presentation include fever, chills, severe flank

pain, nausea and vomiting (Bonkat, et al., 2018).

2. Objective: Compare and contrast objective data section with literature and discuss objective

findings as it pertains to the primary diagnosis and possible differential diagnosis.

Patient has almost no objective data apart from a cloudy and foul-smelling urine. Bacterial

vaginitis usually presents itself without any inflammation but can be distinguished by “fishy”

odor confirmed by whiff test. Vaginitis is also characterized by discharge whose characteristic

relies on causative organism (Paladine & Desai, 2018). Pyelonephritis has characteristic by fever

(> 38°C) and costovertebral angle tenderness (Bonkat, et al., 2018).

3. Assessment: Compare and contrast the integration of the subjective and objective analysis

section to support the appropriate primary diagnosis verses your possible differential diagnosis.

Discuss interrelationships of identified 2 or more illness if pertinent (e.g. HTN, diabetes, obesity
are all related). Support your assessment (diagnosis) with evidence from the literature—beyond

your textbooks.)

Uncomplicated Cystitis is marked by dysuria, that is a burning sensation while urinating, which

is in contrast to vaginitis which usually presents with vaginal pain or soreness. The lack of

inflammation and erythema is another objective sign of vaginitis that differentiate it from a UTI.

Lack of discharge and pruritis which is almost always presents in vaginitis provides another

differentiating criterion as both are present in vaginitis while absent in UTI. Bacterial vaginosis

with its characteristic fishy odor provides one of the best differentiating criteria (Bonkat, et al.,

2018). When compared with Pyelonephritis the generalized systematic signs of fever, chills

clearly distinguish it with uncomplicated Cystitis. Couple that with lack of costovertebral angle

tenderness which is invariably presents in pyelonephritis make the diagnosis of UTI more likely

(Paladine & Desai, 2018). Recurrent cystitis refers to ≥2 infections in six months or ≥3 infections

in one year. In this patient similar episode happened about 8 months ago, thus ruling out

recurrent cystitis and making the diagnosis of uncomplicated Cystitis more likely (Hooton &

Gupta, 2019b). The diagnosis of Uncomplicated Cystitis can be reasonably made based on

focused history (dysuria, frequency and urgency) and a lack of any vaginal irritation or

discharge. Nevertheless, the presence of nitrities and leukocytes do strengthen the diagnosis. In

Pyelonephritis urinalysis also show both nitrites and leukocytes but it is also accompanied by

Red blood cells (Bonkat, et al., 2018).

4. Plan: Compare and contrast identified treatment plans for all identified diagnoses with the

literature. (Provide references for the treatment plan (Evidence-based practice). Explain why you

have selected a medication: give medication name, dose, route, frequency (provide references).
Studies have shown that successful treatment of uncomplicated Cystitis is significantly better

with antimicrobials when compared with placebo. Nitrofurantoin Macrocystals is considered

first-line antibiotic treatment for uncomplicated Cystitis (Bonkat, et al., 2018). I have chosen

twice a day dosing compare to four times a day dosing to ensure better compliance and ease of

taking medication. The success rate in eliminating UTI with Nitrofurantoin is 79-92% with a five

to seven-day course (Hooton & Gupta, 2019a). Though the dysuria usually responds within few

hours of start of antimicrobial treatment, in patients with severe dysuria a 2-day course of

Pyridium 200mg TID for two days has shown to reduce pain (Hooton & Gupta, 2019a). This

symptomatic relief can help patient be more compliant with the antimicrobial therapy and helps

improve quality of life. The non-pharmacological measures like increasing fluid intake and use

of cranberry juice/supplement has proven to prevent stasis and reduce bacteria count decreasing

the risk of infection. Urine culture is not a requisite for an accurate diagnosis, studies have shown

that diagnostic lab values only lead to a minimal increase in accuracy in patients who presents

with typical symptoms of uncomplicated Cystitis (Bonkat, et al., 2018).

 References:

Bonkat, G., Pickard, R., Bartoletti, R., Bruyère, F., Geerlings, S., Wagenlehner, F., ... &

Veeratterapillay, R. (2018). European Association of Urology (EAU) Guidelines on

Urological infections. [PDF] Arnhem, The Netherlands: EAU Guidelines Office.

Retrieved from https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Urological-

Infections-2018-large-text.pdf

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care:

the art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis

Company.

Hooton, T. M., & Gupta, K. (2019a). Acute simple cystitis in women. Uptodate. Retrieved from

https://www.uptodate.com/contents/acute-simple-cystitis-in-women.

Hooton, T. M., & Gupta, K. (2019b). Recurrent simple cystitis in women. Uptodate. Retrieved

from https://www.uptodate.com/contents/recurrent-simple-cystitis-in-women

Paladine, H. L., & Desai, U. A. (2018). Vaginitis: diagnosis and treatment. American family

physician, 97(5).