SOAP Note for Urinary Tract Infection, Essay Example

Chief Complaint

Patient presents with mild fever, low back pain, and “burning” sensation while urinating for one week.

Subjective

The patient reports the burning sensation began after an overnight stay at the hospital one week ago. He states he fell down a flight of stairs at work and was kept overnight for observation. The patient reports that he was “fine” but the hospital was disorganized and “dirty.” He reports the hospital staff insisted administering a catheter and the nurse failed three times to insert the catheter properly.

The patient reports difficulty initiating urination but is experiencing increased urgency and nocturia. He reports a “burning” sensation and rates it a 7/10. He states his urine “smells funny” and describes a “cloudy” appearance. He states he is experiencing mild rectal pain, but is having no problems with bowel movements. He reports no blood in the urine.

The patient reports low back pain and diffusely points to his lower back. He rates this pain a 4/10 and states it is a constant ache. States his wife became concerned when he began running a temperature and experiencing mild nausea last evening.

Objective

Patient is an African American male of 46 years. His blood pressure is 122/78 mmHg, respiratory rate is 16 cycles per minute, and pulse rate is 68 beats per minute.  His height is 5’11 and he weighs 178 pounds. His temperature is 99.7 degrees Fahrenheit. Ambulation and gait were normal.

Frontal and maxillary sinuses were not tender to palpation. Lymphatic exam of head and neck was within normal limits; submandibular and sublingual lymph nodes were tender to palpation and slightly enlarged. Examination of cranial nerves I-XII were within normal limits and unremarkable. Visual inspection of eyes and ears were normal and unremarkable.

Visual inspection of nose and throat were normal and unremarkable. Auscultation of heart and lungs were within normal limits.

Abdominal sounds are within normal limits. Mild pain is reported with palpation of kidneys and suprapubic region. Murphy’s Punch was negative to pain. The prostate was not enlarged and was not painful to palpation. There was no pain with palpation of liver and spleen.

Active range of motion for lumbar spine was full and did not reproduce the pain. A significant other finding of mild nausea occurred upon flexion. Patellar and Achilles reflexes were 2+ and even bilaterally.

All values for the complete blood count with differential are within normal limits and unremarkable with the exception of an increased white blood cell count of 14.2. All values for the white blood cell differential were within normal limits and unremarkable with the exception of neutrophila of 76% and increase in stab cells at 10%. Sedimentation rate is 22mm/hr. All values for blood chemistry are within normal limits and unremarkable. A clean catch urinalysis revealed the presence of nitrites and leukocyte esterase. A microanalysis of the urine sample revealed casts of white blood cells, mucous strands, and trace amounts of bacteria.

Assessment:

The patient has a urinary tract infection complicated by pyelonephritis. Patient’s mild temperature of 99.7 degrees Fahrenheit and tender and enlarged submandibular lymph nodes indicate an infection. Pain upon palpation of the kidneys and suprapubic region localize infection to urinary tract.

Test results indicate that the patient’s back pain is not mechanical in nature and neurological function is intact. Prostate evaluation did not reveal an enlarged prostate. Bowel sounds were normal and liver and spleen appear to be intact. Sinuses, eyes, ears, nose, and throat appear to be free of obstruction and infection. Heart and lung auscultation indicated no pathology.

To confirm the objective results of the examination a complete blood count with differential was ordered. High amounts of leukocytes were of concern and the neutrophilia and high stab cell count with sedimentation rate indicates bacterial infection. The presences of nitrites and leukocyte esterase in the urinalysis required a microanalysis of the urine sample. This revealed casts of white blood cells, mucous strands, and trace amounts of bacteria. The infection is bacterial, in the urinary tract, and has spread to the kidneys.

Plan

The patient will be prescribed 500 milligrams of Ciprofloxacin for ten days. He is instructed to drink plenty of water and limit caffeine, sugar, and alcohol from his diet while on medication. If symptoms do not remit in 72 hours, an ultrasound of the bladder and kidneys will be considered.

Clinician Signature:                                                                                 Date: