Running head: Nursing SOAP Note $ Journal 1

Nursing SOAP Note and Journal

Name

Institution
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SUBJECTIVE: What details did the patient provide regarding his or her personal
and medical history?

Past Medical History

Hospitalizations and Health Maintenance

Surgical History: Urinary Track Infection at age 21.

Chronic Medical Problem

Psychiatric History: None

Immunizations: Patient does not receive regular flu vaccines.

Childhood Illnesses: Suffered from Asthma and Chicken pox.

Transfusions: None

Allergies: None

Screening tests: Patient does not go to see eye problems and has no eye problems. She

also doesnt see the dentist regularly but will make an appointment today. She has to

broken molars.

Has had a Pelvic Exam, Cervical smear and STD screening.

History of Present Illness:

Location: The patient feels pain at her urinary track.

Quality

Severity: The patient rates her pain at 6/10.

Timing (Frequency): Normally, patients normal urinary frequency was four times

everyday but for the past three days, the frequency has increased to up to six to eight

times.

Context: Patient says that she started experiencing symptoms of urinary track

infection three days ago. Her frequency of going to the bathroom increased from four

times daily to six/eight times daily. In addition to that, she experiences increased
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burning during urination while urinating. She started experiencing lower abdominal

pains and thus made an appointment today.

Relieved by: The patient says that pain reduces a little between the urgency episodes.

Worsened by: Pain increases when she goes to the bathroom and cannot produce any

urine.

Associated signs and symptoms: Increased urinary frequency, burning sensation when

urinating, and abdominal pains

Review of Symptoms (Systems)

Patient does not suffer from fever, chills, fatigue, malaise and headache.

Constitutional

Eyes: Patient has no blurry vision, eye pain, itching or drainage.

Ears, Nose, Mouth, Throat: Patient does not suffer from ear pain, fullness, popping,

and loss of hearing or drainage. Does not suffer from nose drainage, loss of smell and

no sinus pressure. Has no sore throat or loss of taste and bleeding gums. However

suffers from tooth and gum pain and has difficulty in chewing.

Cardiovascular: Has no chest pains, syncope and shortness of breath.

Gastrointestinal: Not difficulty in swallowing. Denies nausea, vomiting, constipation,

melena, indigestion, reflux, dysphagia, diarrhea and loss of appetite.

Genitourinary: Bilateral lower quadrant abdominal pain/pressure.

Musculoskeletal: Complains of dysuria, polyuria. Burning, frequency and incomplete

bladder emptying without hematuria, offensive odor of urine or back/flank pain.

Skin and/or breasts: Denies rashes, moles, itching, acne or other skin changes.

Neurological: Denies any memory loss, imbalance and weakness.

Endocrine: Denies palpitations, orthopnea and syncope.

Hematologic/Lymphatic: Denies cough and sputum production.

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Allergic/Immunologic: Patient suffers from no allergies.

Last Menstrual Period: 7/14/2011, lasted five days. Normal menstruation for patient.

Social History

Cultural Background

Education Level: N/A

Economic Condition: Patient unemployed and boyfriend works at a chicken

processing plant.

Number in household: Four, including the patient.

Marital Status: Stays with boyfriend

Lives with her boyfriend (father of her children)

Children: Two children, ages 1 and 3.

Occupation: Unemployed

Occupational Health Hazards. N/A

Nutrition: Cooks a lot of prepared frozen food.

Exercise: Does not have a regular exercise routine.

Tobacco use: She smokes packet per day.

Caffeine: N/A.

Sexual Activity: N/A

Contraception: N/A

Alcohol/recreational drug use: Does not drink alcohol.

Narcotic: Short history of prescription narcotic abuse but has been clean for two

months.

Safety Measures: Wears seat belt.

Family History

Mother had lung cancer, heart disease, hypertension and diabetes.

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Father had diabetes.

Mothers uncle had problems with alcoholism.

OBJECTIVE: What observations did make during the physical assessment?

General: The patient is alert and awake and also responds appropriately and she is not

feverish. Weight is 129, height is 63 inches and BMI is 22.7.

Skin: Patients skin is warm and dry. Skin tone is also normal.

HEENT

Head: Head is normocephalic, a traumatic and symmetrical.

Eyes: Sclera and conjunctiva clear, no discharge, Pupils equal, round, and

reactive to light and accommodation.

Ears: Bilateral external ear size and shape. Both ears have three piercings

each, no masses or tragal tenderness. Patent canals with no odor, discharge or foreign

bodies bilaterally. Internal ear inspection shows a pink canal with a tympanic

membrane that is pearly gray, concave, with light reflex and visible bony landmarks

without ear cerumen.

Nose: Nares patent bilaterally, nasal septum midline; turbinates pink and

moist without nasal discharge. Mucus membranes pink, moist without lesions, hard

and soft palate intact.

Mouth: Uvula midline, tongue midline, sensitive gag response

Teeth/Gums: No teeth missing, 2 broken molars to the left upper and lower

dentit, evidence of active decay, gum redness, no puss or bleeding visualized.

Pharynx: Patient suffers from trachea midline without any lymphadenopathy.

Pharynx pink, tonsils 1+ without exudates or pitting.

Neck: Patient suffers from neck midline.

Heart: VS-BP 102/60, HR: 76, RR: 18

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Lungs: Clear to auscultation without crackles, wheezes or rhonchi. Normal S1 and

amp; S2 without any spits, skips, rubs, gallops or murmurs.

Abdomen: Flat and symmetrical. No scars, dilated veins, rashes, lesions, peristalsis or

pulsations visible. Umbilicus midline, without bulges. Bilateral abdominal strie from

childbirth. Active bowel sounds in all four quadrants, no aortic, renal, iliac or femoral

bruits auscultated, no friction rubs heard over the liver or spleen. Abdomen is soft,

non-tender to light and deep palpation of upper quadrants and tender to light and deep

palpation of lower quadrants.

Back: No costovertebral angle or back tenderness to palpation.

Musculoskeletal: Maxillary and frontal sinuses non-tender tender to palpation.

No palpable masses or hepatosplenomegaly. Spleen and kidneys not felt. Aortic

pulsations slightly palpable.

ASSESSMENT: What were your differential diagnoses? Provide a minimum of

three possible diagnoses. List them from highest priority to lowest priority. What was

your primary diagnosis and why?

Possible diagnoses: Acute Pyelonephritis, Bladder Cystitis and Unitary Tract

Infection.

Most likely diagnosis: The patient is suffering from Unitary Tract Infection

and it was selected because the patient had the following symptoms; Urinary urgency

and burning sensation with urination, incomplete bladder emptying and Atypical

infections of the lower urinary tract.

PLAN: What was your plan for diagnostics and primary diagnosis? What was your
plan for treatment and management including alternative therapies?
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Laboratory Testing: Urine Dipstick in office, results were positive for

leukocytes and nitrates with trace blood. Urine Culture, Sensitivity and microscopy

sent to the lab to confirm diagnosis.

Medications: Ciproflaxin 500mg PO BID for three days (Drugs short term therapy

duration)

Patient Education: A urinary tract infection stems from an infection in the kidneys,

bladder or urethra. These are mostly caused by E. Coli., Staph Saprophyticus and

others found in normal bowel flora.

Follow-up: No follow up visit is necessary for the UTI. Follow up with a dentist for

both the broken teeth and regular cleanings needed.

REFLECTION NOTES:

Urinary tract infections are prevalent in women and five to ten percent of adult

women suffer from unitary tract infection within a year, in others, it occurs three times

or more. Diagnosis is based on urine dipstick, microscopic urinalysis and urine

culture. Treatment involves antibiotic therapy.

References
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(2013). Guidelines on Urological Infections. M. Grabe. Retrieved 29 July 2016, from

https://uroweb.org/wp-content/uploads/18_Urological-infections_LR.pdf

(1997) Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary

tract infection. Infect Dis Clin North Ame Sep;11:(3)551-81.

http://www.ncbi.nlm.nih.gov/pubmed/9378923

Sthrer M, Blok B, Castro-Diaz D, et al. EAU Guidelines on Neurogenic Lower

Urinary Tract Dysfunction. Eur Urol. 2009 Jul; 56(1):81-8.

http://www.ncbi.nlm.nih.gov/pubmed/19403235

Arcangelo, V.P. & Peterson, A.M. (2006). Pharmacotherapeutics for advanced

practice: A practical approach (2 nd ed.). Philadelphia: Lippincott Williams

& Wilkins.

Bickley, L. S. (2009). Bates pocket guide to physical examination and history taking

(6 th ed.).

Philadelphia: Lippincott Williams & Wilkins.

Domino, F. J. (Eds.). (2010). The 5-minute clinical consult. Philadelphia:

Lippincott Williams &

Lee, U. J. & Goldman, H. B. (2011, March 15). Urinary tract infections in

women.. Epocrates,

Inc. Retrieved July 30, 2011 from

https://online.epocrates.com/noFrame/showPage.do?

method=diseases& MonographId=77