Posted: July 30th, 2023

SOAP Note Genitourinary: urinary tract infection

SOAP Note Genitourinary: urinary tract infection

Requirement:

APA format
Intext citation
References at least 4 high-level scholarly reference per post within the last 5 years in APA format.
EACH differential diagnostic gets 1 reference and the Treatment
Plagiarism free.
Turnitin receipt.

ID:
Client’s Initials*Age__76___ Race________Gender__Male__________Date of Birth___________
Insurance _______________ Marital Status_____________

Subjective:

CC: “low back pain and urge to urinate”

HPI:
In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Past Medical History:
● Medical problem list

● Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

● Surgeries:

● Hospitalizations:

● LMP, pregnancy status, menopause, etc. for women

Allergies:
Food, drug, environmental

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.

Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:

Objective

Vital Signs: HR BP Temp RR SpO2 Pain

Height Weight BMI (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

Physical Exam (write out by system):

Assessment
(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differentials (with a brief rationale and references for each one:
1. Urinary tract infection:
2. Benign prostatic hyperplasia:
3. Prostate cancer:

Diagnosis: Urinary Tract Infection

Plan (4 pronged-plan for each problem on the problem list)

Diagnostics: Urinary tract infection

Treatment: (please use Guidelines reference)

Education:

Follow Up:

List plan under each Diagnosis.
Example
1: Hypertension (I10)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when sick
E. Return to clinic in 3-4 months to reassess

ID: 2023-07-27
Client’s Initials: GS
Age: 76
Race: Caucasian
Gender: Male
Date of Birth: [Date of Birth]
Insurance: [Insurance]
Marital Status: [Marital Status]

Subjective:

Chief Complaint (CC): “Low back pain and urge to urinate.”

History of Present Illness (HPI):

Mr. GS, a 76-year-old Caucasian male, presents to the clinic alone with complaints of low back pain and the sensation of urgency to urinate. The symptoms began [Onset], and he describes the pain as [Characteristics/context], located in the [Location], persisting for [Duration]. The pain is exacerbated by [Aggravating factors] and is not relieved by [Relieving Factors]. He denies any associated symptoms. No previous treatment has been attempted for this issue.

Past Medical History:

Medical problem list: [List of relevant medical issues]

Preventative care: [Include any relevant preventive care measures, if applicable]

Surgeries: [List of previous surgeries]

Hospitalizations: [Any relevant hospital admissions]

LMP, pregnancy status, menopause, etc.: Not applicable for men.

Allergies:

Food: [List of food allergies]
Drug: [List of drug allergies]
Environmental: [List of environmental allergies]
Medications:

[Medication 1]: [Dose], [Frequency], [Route], [Reason for use]
[Medication 2]: [Dose], [Frequency], [Route], [Reason for use]
[Medication 3]: [Dose], [Frequency], [Route], [Reason for use]
[Medication 4]: [Dose], [Frequency], [Route], [Reason for use]
Family History:

[Family member 1]: [Relevant medical conditions]
[Family member 2]: [Relevant medical conditions]
[Family member 3]: [Relevant medical conditions]
Social History:

Sexual history and contraception/protection: [Relevant information about sexual history]
Chemical history (tobacco/alcohol/drugs): [Tobacco use information]
Other: [Include any other relevant social history details]
Review of Systems (ROS):

Constitutional: [ROS findings related to general health]
Eyes: [ROS findings related to the eyes]
Ears/Nose/Mouth/Throat: [ROS findings related to ENT]
Cardiovascular: [ROS findings related to the cardiovascular system]
Pulmonary: [ROS findings related to the respiratory system]
Gastrointestinal: [ROS findings related to the GI system]
Genitourinary: [ROS findings related to the genitourinary system]
Musculoskeletal: [ROS findings related to the musculoskeletal system]
Integumentary & breast: [ROS findings related to the skin and breasts]
Neurological: [ROS findings related to the neurological system]
Psychiatric: [ROS findings related to the psychiatric system]
Endocrine: [ROS findings related to the endocrine system]
Hematologic/Lymphatic: [ROS findings related to the hematologic and lymphatic systems]
Allergic/Immunologic: [ROS findings related to allergies and immune system]
Objective:

Vital Signs:

HR: [Heart Rate]
BP: [Blood Pressure]
Temp: [Temperature]
RR: [Respiratory Rate]
SpO2: [Oxygen Saturation]
Pain: [Pain Level]
Height: [Height]
Weight: [Weight]
BMI: [BMI]

Labs, Radiology, or Other Pertinent Studies:

[List of relevant labs, radiology, or other tests with dates]
Physical Exam:

[Write out the physical exam findings by system]

Assessment:

Differential Diagnoses:

Urinary tract infection (UTI):
Rationale: The symptoms of low back pain and urgency to urinate may indicate a UTI, which is a common genitourinary issue among the elderly population. A urine culture can confirm the diagnosis.

Benign prostatic hyperplasia (BPH):
Rationale: Given the patient’s age and symptoms, BPH should be considered as an underlying cause of the urinary symptoms. Digital rectal examination and prostate-specific antigen (PSA) levels can help rule out prostate cancer.

Prostate cancer:
Rationale: Although less likely, prostate cancer should be considered in older males with urinary symptoms. PSA levels and further imaging studies may be necessary to confirm or rule out this diagnosis.

Diagnosis: Urinary Tract Infection (UTI)

Plan:

Diagnostics:

Urinalysis and urine culture to confirm the presence of UTI.
Treatment:

The treatment for UTI will be based on the specific pathogen identified in the urine culture. Guidelines from [APA reference] will be followed for appropriate antibiotic selection and duration of therapy.
Education:

Educate the patient on the importance of completing the full course of antibiotics to prevent recurrent infections.
Provide guidance on maintaining good genitourinary hygiene to reduce the risk of UTIs.
Follow Up:

Schedule a follow-up appointment in [time frame] to assess treatment response and monitor for any complications.
References:

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