- ***** PATIENT AJ IS A 37 Y/O FEMALE WITH UTI ( STINGING IN URINE, FREQUENCY AND URGENCY) SYMPTOMS*****
- COMPLETE COMPREHENSIVE SOAP NOTE
- \Subjective: What details did the patient provide regarding the personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
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Walden University Health & Medical Worksheet
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Introduction: In this assignment, we will be creating a comprehensive SOAP note for a patient with urinary tract infection (UTI) symptoms. The SOAP format is commonly used in healthcare to organize patient information and make clinical decisions. We will go through each section of the SOAP note, including subjective, objective, assessment, plan, and reflection notes.
Subjective: The patient, a 37-year-old female, reported symptoms of stinging in urine, frequency, and urgency. The patient provided a medical history of recurrent UTIs and reported previous episodes of similar symptoms. She denied any recent changes in sexual activity, but mentioned a family history of urinary tract issues.
Objective: During the physical assessment, the patient appeared uncomfortable due to her symptoms. Vital signs were within normal limits. Upon abdominal examination, no tenderness or distension was noted. There were no signs of fever or flank pain. The patient’s urine sample revealed the presence of leukocytes and nitrites, suggesting a probable UTI. No other morbidities or psychosocial issues were identified during the assessment.
Assessment: Based on the patient’s symptoms and the objective findings, the differential diagnoses for this case include:
1. Urinary tract infection (Cystitis) – CPT code: 87798; ICD-10 code: N39.0
2. Kidney infection (Pyelonephritis) – CPT code: 87880; ICD-10 code: N10
3. Interstitial cystitis – CPT code: 87177; ICD-10 code: N30.1
The primary diagnosis is urinary tract infection (cystitis) based on the patient’s symptoms, positive urine analysis, and absence of more severe signs like fever or flank pain.
Plan: The plan for this patient includes:
1. Diagnostics: A urine culture and sensitivity test will be conducted to identify the specific bacteria causing the infection and determine the most effective antibiotic treatment. Other diagnostic tests such as renal ultrasound or CT scan may be considered if the symptoms worsen or there are signs of kidney involvement.
2. Treatment and Management: Pharmacologic treatment with a course of antibiotics, such as trimethoprim/sulfamethoxazole or nitrofurantoin, will be prescribed based on the urine culture results. Non-pharmacologic measures include increasing fluid intake and implementing proper hygiene practices. The patient will be advised to finish the prescribed antibiotics, follow-up in 7-10 days, and report any worsening symptoms or new developments.
3. Follow-up Parameters: The patient will be scheduled for a follow-up appointment in 7-10 days to assess symptom resolution and ensure the success of the prescribed treatment.
Reflection notes: During this patient evaluation, my “aha” moment was recognizing the importance of obtaining a thorough medical and familial history. The patient’s recurrent UTIs and family history of urinary tract issues helped to support the diagnosis and guided the management plan. If I were to encounter a similar patient evaluation in the future, I would consider discussing preventive measures with the patient, such as voiding after sexual intercourse, proper hygiene practices, and regular hydration to reduce the risk of future UTIs.