Comprehensive Soap note.
Remember that this is a mock patient. You will make up the history and exam findings as if you have interviewed this patient and performed an exam. You are required to use a SOAP note template with citations and references in APA format. You will include three ddx with supportive documentation, citations, and references! Please be aware Turnitin similarity should be less than 20%
If the information was not provided in the case study, be creative and ask yourself what would be important for me to ask this patient if he were in my office. All systems should be included in the ROS and for the Physical Exam
Use the following case to complete a focused SOAP note:
A 27-year-old female came to the office complaining of dysuria, nocturia, and hypogastric abdominal pain. Pt denies fever or CVT. Denies pass medical history. College student doing her master, still living at the parents’ house. Denies tobacco, alcohol or illicit drugs use included marijuana. In stable relationship with his partner for last 4 years. She reports sexual activities using condom for protection.
Family history: moder alive with HTN, father and sister healthy.
Medications: Macrobid 100 mg twice a day PO for 10 days.
Labs: Urine dipstick shows high concentration of nitrites and leukocytes. Urinalysis and urine culture is requested.
Pt education: Pt is advised to drink plenty of water, to not eat heat or spicy food, and to clean the urethral external part with light soap and water. Pt was advised to abstain from sexual activity for the next week. She was advised that the urine can turn yellow when she is taking the medication.
Follow-up: return to the office 4 weeks or earlier if the problems worsen. Urinalysis with culture two weeks after finishing the antibiotic.
At the end of the visit, the patient understands the diagnosis, medications’ benefits, and adverse effects. The patient agrees to continue the present treatment, and if the patient does not feel better should visit the nearby emergency room.
On the exam, his vital signs are BP 110/70; P 64; R 14; T 98.2; Pulse ox: 98%.
The patient, a 27-year-old female, presents with complaints of dysuria, nocturia, and hypogastric abdominal pain. The patient denies any history of fever or chills. She has no significant past medical history and is currently living at her parents’ house while pursuing her master’s degree. The patient denies any tobacco, alcohol, or illicit drug use, including marijuana. The patient is in a stable relationship with her partner for the last 4 years and reports sexual activities using a condom for protection.
Vital signs: BP 110/70; P 64; R 14; T 98.2; Pulse ox: 98%
General: The patient appears comfortable, well-nourished, and well-hydrated.
HEENT: PERRLA, EOMI, no cervical lymphadenopathy, no pharyngeal erythema or exudates.
Cardiovascular: Regular rhythm, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally without wheezes, rales, or rhonchi.
Abdominal: Soft, non-tender, non-distended, no hepatosplenomegaly.
Genitourinary: Urethral meatus normal, no vaginal discharge, external genitalia normal.
Musculoskeletal: No joint swelling or tenderness.
Skin: No rashes or lesions.
Neurological: Cranial nerves II-XII grossly intact.
The patient presents with symptoms suggestive of a urinary tract infection, including dysuria, nocturia, and hypogastric abdominal pain. Urine dipstick shows high concentration of nitrites and leukocytes, and urinalysis and urine culture have been ordered. Treatment with Macrobid 100 mg twice a day PO for 10 days has been prescribed.
Pyelonephritis: This diagnosis cannot be ruled out until urine culture and urinalysis results return.
Urethritis: Although the patient reports no discharge, this diagnosis should be considered if symptoms do not improve with treatment.
Interstitial cystitis: This diagnosis should be considered if symptoms do not improve with treatment or if the urine culture is negative.
The patient was advised to drink plenty of water, avoid spicy or acidic food, and clean the urethral external part with light soap and water. She was advised to abstain from sexual activity for the next week. The patient was also informed that the urine may turn yellow when taking the medication.
Follow-up with the patient in 4 weeks or earlier if symptoms worsen. Urinalysis with culture two weeks after finishing the antibiotic. The patient has been informed to visit the nearby emergency room if she does not feel better.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Centers for Disease Control and Prevention. (2019). Sexually transmitted diseases treatment guidelines. Retrieved from https://www.cdc.gov/std/treatment-guidelines/clinical.htm
Lexicomp. (2021). Macrobid. Retrieved from https://www.lexicomp.com/products/drug-information/patient-education/macrobid
National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Urinary tract infections in adults. Retrieved from https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-tract-infections-adults