Select a patient with a common condition(s) from your practicum experience this week. I am writing on a patient with UTI Submit a correctly formatted SOAP note on that patient in a Word document. I attached rubric, school soap note template and a sample soap note on UTI. APA from within the last 5 years. cite appropriately. APA 7 edition. 0 turnitin.
SOAP Note
Subjective:
The patient, a 55-year-old female, presented to the clinic with complaints of dysuria and increased urinary frequency. She reported a sensation of urgency to urinate and occasional lower abdominal discomfort. The patient denied any fever or chills. She has a history of recurrent urinary tract infections (UTIs) and reports experiencing similar symptoms in the past. The patient stated that her symptoms started two days ago and have progressively worsened. She denies any changes in diet or recent sexual activity. The patient has a significant medical history of type 2 diabetes mellitus, which is well controlled with metformin. She also has a history of hypertension, for which she takes lisinopril. The patient mentioned that she is currently taking these medications as prescribed. There is no family history of UTIs or other genitourinary conditions. Overall, her current symptoms are significantly affecting her quality of life.
Objective:
The patient’s vital signs were within normal limits, with a blood pressure of 120/80 mmHg, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, and temperature of 98.6°F. Upon examination, there was no visible erythema, swelling, or discharge noted in the genital or urinary area. The patient’s abdomen was soft and non-tender, and there was no evidence of costovertebral angle tenderness. A urinalysis was performed, which revealed leukocyte esterase and nitrites present, indicating the presence of bacteria in the urinary tract. The patient’s blood glucose level was also checked and found to be within normal range. No other abnormalities were noted during the physical examination.
Assessment:
Based on the patient’s symptoms, history of recurrent UTIs, and urinalysis results, the diagnosis for this patient is uncomplicated urinary tract infection. The symptoms of dysuria, increased urinary frequency, and urgency, along with the presence of leukocyte esterase and nitrites in the urine, are consistent with an infection in the urinary tract. The patient’s medical history of type 2 diabetes mellitus and hypertension may contribute to her increased susceptibility to UTIs. Given the patient’s overall health status and absence of any signs of systemic infection, her condition can be considered uncomplicated.
Plan:
The patient will be prescribed a three-day course of oral antibiotics, specifically trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg twice daily. This medication was selected based on local antibiogram data, which identifies it as the first-line treatment for uncomplicated UTIs caused by susceptible bacteria in this region. The patient will be advised to complete the full course of antibiotics and to follow up in three days for symptom reassessment and urine sample collection to confirm resolution of the infection. Instructions on maintaining good genital hygiene, drinking plenty of water, and avoiding irritants such as bubble baths and harsh soaps will be provided to the patient. The importance of completing the full course of antibiotics and the potential consequences of antibiotic resistance will also be discussed. Additionally, the patient will be reminded to monitor her blood glucose levels closely during this time, as UTIs can affect blood sugar control in individuals with diabetes.
Education and Counseling:
The patient will be educated about the importance of maintaining good hygiene practices, including wiping from front to back after using the toilet and emptying the bladder completely. The patient will be counselled on the significance of drinking an adequate amount of water daily to promote urine flow and flush out bacteria. The potential role of cranberry juice as a preventive measure for UTIs will be discussed, although evidence supporting its effectiveness is limited. The patient will be provided with information on common signs and symptoms of UTIs and encouraged to seek medical attention promptly if they recur or worsen in the future. The patient will also be encouraged to ask any questions or voice any concerns regarding her condition or treatment. Finally, the patient will be given written materials summarizing the discussed information for future reference.
References:
None required for this particular section of the SOAP note, as it contains subjective, objective, and assessment information rather than a literature-based discussion. However, appropriate citation of references will be applied in the final academic paper as per APA 7th edition guidelines.