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SOAP Note Template

Encounter date: ___15Tth Jan, 2022_____________________

Patient Initials: __A.K____ Gender: M/F/Transgender _Female___ Age: __61___ Race: __Black___ Ethnicity __African American__

Reason for Seeking Health Care: __”I have been having pain in the pelvic, the urgency to urination, burning sensation and pain during urination”____________________________________________

HPI: A.K is a 61-year-old African American female patient who comes to the clinic with the

complaint of pelvic pain that tends to radiate from her lower back, flank pain in the eft, vaginal

discharges that began 8 days ago, the burning sensation, and pain, especially during urination.

She reported having taken Tylenol 500 mg 3 hours ago that assisted in stopping the pain. She

denies a feeling of nausea, vomiting, and abdominal pain. She was also reported to have been

diagnosed with a urinary tract infection in the previous years. She denies experiencing chest

pain, pressure, or any discomfort in the chest.

Allergies(Drug/Food/Latex/Environmental/Herbal): she denies allergies to drugs, food, latex, herbals, and the environment.

Current perception of Health: she perceives her overall health as fair.

Past Medical History � Major/Chronic Illnesses: has a history of diabetes, asthma and hypertension � Trauma/Injury: denies any trauma or injury � Hospitalizations: denies the recent or past hospitalization

Past Surgical History: Reports no past surgical procedure

Medications: the client is presently on nifedipine 60 mg OD, metoprolol tartrate 25 mg BID, metformin 500 mg BID, multivitamin OD, and the antibiotic in the past for the treatment of her previous urinary tract infection.

Family History: the father is on medication for diabetes while the mother is on treatment for

hypertension, asthma, and diabetes.

Social history:

Lives: lives with the husband and three children Marital Status: Married Employment

Status: she is an accountant in the family business Current/Previous occupation type:

accountant

Exposure to: ___Smoke_denies___ ETOH __denies__Recreational Drug Use:

_______denies___________

Sexual orientation: __she is in a heterosexual relationship_ Sexual Activity: _she is

faithful hence having only one partner for a sexual relationship___ Contraception Use:

she is in her menopausal stage and denies the use of any contraceptives.

Family Composition: three children and the husband.

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc: The last mammogram performed on June 2021 revealed no abnormality. The last colonoscopy was two years ago and concern was detected. The Pap Smear has performed 5 months ago and reported no abnormality.

Exposures: denies any exposure to drugs, alcohol, and tobacco.

Immunization HX: the immunization is up to date and was recently vaccinated using Pfizer for COVID-19 (15/11/2021)

Review of Systems:

General: she is appropriately dressed, well-groomed, denies loss of weight, energy, chills, and

fever.

HEENT: denies the changes in vision and hearing. She also denies difficulty in swallowing.

Neck: denies the injuries, the tenderness, and the stiffness of the neck.

Lungs: denies shortness of breath, wheezing, and coughing.

Cardiovascular: denies chest pain, pressure, and discomfort.

Breast: denies the discharges, the pain, and the tenderness of the breast.

GI: denies nausea, vomiting, diarrhea, abdominal pain, and changes: in the habits of the bowel or

appetite.

Male/female genital: admits pelvic pain, discharges, spotting of the blood, pain in urination, and

blood in the urine.

GU: reports difficulty in urination, discharges, pain, and burning sensation during the urination

Neuro: denies headache and the syncope

Musculoskeletal: denies joint or muscle pain

Activity & Exercise: she is active, actively involved in the exercise activities such as yoga on the

daily basis

Psychosocial: denies changes in the mood, depression, or anxiety

Derm: denies the presence of rashes, lesions, or itching

Nutrition: reported a balanced diet and reports no changes in appetite.

Sleep/Rest: the sleep pattern is good with no insomnia. Mostly sleep for 8 hours and denies daily

sleep

LMP: 8 years ago.

STI Hx: reports no history of the STIs

Physical Exam

BP 128/80 TPR_ 36__ HR: _82_ RR: _18___Ht. __5’7’’___ Wt. __170 lbs____ BMI

(percentile) __24%___

General: she is alert and oriented, awake, normal mood and affect as well as no challenges in

ambulation

HEENT: she has a normocephalic, atraumatic head with non-visible or palpable masses. There

are translucent TMs of the ear with the appearance of the ossicles and intact hearing. The eye has

intact visual acuity, clear conjunctiva, non-icteric sclera, and intact EOMs. There is PERRLA,

normal optic discs and vessels, with the absence of the exudates or hemorrhages. The nose lack

external lesions, non-inflamed mucosa, and the normal septum and turbinate. There is non-

inflamed mucosa, no tonsillar hypertrophy, and exudates of the throat.

Neck: she has a supple neck with no lesions, adenopathy, and bruits. There is non-enlarged and

non-tender thyroid.

Pulmonary: there are clear lung sounds upon auscultation. There are no rales, wheezing, and

cracks

Cardiovascular: there is the absence of gallop, murmur, thrills, or cardiomegaly.

Breast: there is no abnormality of the nipples, no movable masses, no palpitation, and tenderness.

GI: there are normal bowel sounds, no distention, tenderness, organomegaly, hernia, or masses

detected.

Male/female genital: there is normal pubic hair distribution, small discharges from the vagina,

and pain

GU: dullness of the bladder, discharge, pelvic pain, and tenderness of the left costovertebral

angle.

Neuro: there are intact cranial nerves. Sensitive to pain and touch with the normal DTRs in the

lower and upper extremities.

Musculoskeletal: the patient has a normal gait and station. There is an absence of misalignment

and asymmetry.

Derm: the skin is a good turgor with the absence of rashes and unusual bruises or lesions.

Psychosocial: she can express herself

Misc. the BMI reveals 25 percent

Plan:

Differential Diagnoses

1. Urethritis (N34)

2. Pelvic Inflammatory Disease (PID) (N73.9)

3. Vaginitis (N77.1)

Principal Diagnoses

1. Urinary tract infections (N39.0)

2. Acute Pyelonephritis (N10)

Plan

Diagnosis Urinary tract infections (N39.0)

Diagnostic Testing: urinalysis performance using UriScan kits and performing culture test

Pharmacological Treatment: prescribing the Bactrim DS 800 160 mg BID for two weeks and

Tylenol for the management of pain.

Significant Data/Contributing

There is performance of the laboratory procedures and this include the urinalysis, the urine culture, and the sensitivity tests for the presence of the microbes. There is also complete blood count (CBC) to determine whether there is elevation or reduction of the WBC. Other tests include the chemistry profile for checking the BUN levels and the serum creatinine.

Education: she is advised to take plenty of water, rest, and ensure frequent washing of hands.

Advised to take Tylenol for fever and mild pain, ensure that there is an increase in food

with fiber, and remain physically active. She is informed about the importance of the

completion of antibiotic medication even when the symptoms start to disappear. Advised to

avoid the spermicidal products and use of feminine hygienic sprays or douches.

Referrals: None

Follow-up: follow up for the ultrasound test procedure after two weeks.

Anticipatory Guidance: advised to avoid smoking, alcohol, and ensure well rehydration. She is

informed about the side effects of the medications and what should be done during the

reaction.

Diagnosis Acute Pyelonephritis (N10)

Diagnostic Testing: ultrasound

Pharmacological Treatment: use Percocet PRN for 3 days and increase fiber foods

Education: take medication as per instructions, change the lifestyle, avoidance of stress, do

active exercise for at least 3 or four days, drink plenty of water, avoid alcohol, and continue

with the medications.

Referrals: None

Follow-up: provided with follow-up in the next 14 days

Anticipatory Guidance: ensure well rehydration, avoid stress, maintain a healthy diet, ensure

that the genital area is cleaner, and use mild soap and rinsing with water.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

DEA#: 101010101 STU Clinic LIC# 10000000

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

Patient Name: (Initials)________A.K______________________ Age ___61________

Date: ___15th Jan 2022____________

RX ____Bactrim DS__________________________________

SIG: 800 160 mg orally BID for 7/14

Dispense: _____14______ Refill: ______0___________

No Substitution

Signature: ____________________________________________________________

References

Gharbi, M., Drysdale, J. H., Lishman, H., Goudie, R., Molokhia, M., Johnson, A. P., ... & Aylin, P.

(2019). Antibiotic management of urinary tract infection in elderly patients in primary care and its

association with bloodstream infections and all-cause mortality: population-based cohort study.

BMJ, 364. Doi.https://www.bmj.com/content/364/bmj.l780

Montalbetti, N., Dalghi, M. G., Bastacky, S. I., Clayton, D. R., Ruiz, W. G., Apodaca, G., & Carattino,

M. D. (2022). Bladder infection with uropathogenic Escherichia coli increases the excitability of

afferent neurons. American Journal of Physiology-Renal Physiology, 322(1), F1-F13.

https://doi.org/10.1152/ajprenal.00167.2021

Patel, H. B., Soni, S. T., Bhagyalaxmi, A., & Patel, N. M. (2019). Causative agents of urinary tract

infections and their antimicrobial susceptibility patterns at a referral center in Western India: An

audit to help clinicians prevent antibiotic misuse. Journal of family medicine and primary care,

8(1), 154. DOI: 10.4103/jfmpc.jfmpc_203_18