Running head: CASE STUDY: URINARY TRACT INFECTION
SOAP Note: Urinary Tract Infection
Identifying Data and Chief Complain
A 20-year-old female single and Hispanic patient comes to the clinic complaining of
urgency and intermittent flow and “pain, burning, fever, blood in urine and low back pain”. She’s
describes the pain and burning as moderate (4) when the symptoms started yesterday morning
with “spots of bleeding in the toilet paper” and the pain progress to severe (7) in the afternoon
with “a lot of red bleeding”. The patient refers that she went to the ER the in the evening and
they administered IV fluids and Toradol I/M for pain. CBC and U/A tests were performed.
Patient says that the pain improved, but all symptoms came back after few hours. No medications
were prescribed for home.
Subjective Symptoms
1. “Progressive and intense pain in low abdomen.”
2. The pain is associated with “burning, fever, chills and blood in urine.”
Subjective Data
Past medical history (PMH): Patient refers frequent migraines and a hiatal hernia. Patient refers
no appetite or weight changes. No other chronic diseases reported.
Family history: Her mother is a 46-year-old woman with migraines and hiatal hernia history.
Mother went under a surgery three weeks ago (lipoma “golf ball size” in left axilla}, no other
chronic diseases reported. Her father is a 54-year-old man with no history of chronic diseases.
Patient’s brother is a 22-year-old man with no history chronic diseases. Grandmother, from
mother’s side, is alive and has hypertension, diabetes mellitus and history of urinary stones. .
Grandfather from mother’s side, had an open heart surgery after a myocardial infarction ten years
ago, he doesn’t has other chronic diseases. She doesn’t have knowledge about her other
grandparents from father’s side health, both are alive.
, CASE STUDY: URINARY TRACT INFECTION
Past social history (PSH): The patient doesn’t smoke or drink alcohol. She’s Catholic. The
patient works part-time in a pizzeria five hours/three days a week. She study the sophomore year
at University of Puerto Rico, Carolina Campus. She goes to the gym three or four times a week
and the others days she “walks a lot at the university”. She states that her diet is high in protein
and fiber, low in carbohydrates and includes lactate: milk, cheese and butter.
Immunization: All vaccines are up to date including Human Papilloma Virus, Varicella and
Influenza (two months ago).
Allergies: No known allergies (NKA).
Surgical history: Never been submitted to a surgery.
Medication history: Patient refers that her gastroenterologist prescribed her Protonix (one a day
½ hour before breakfast) and Carafate (one cap) with each meal every day. She’s refers that “I
never skip a dose”.
Subjective Review of Systems
Constitutional: Patient indicates she has fever, no chills, no weight changes and no fatigue.
Skin: She indicates that doesn’t have lessions, acne dry skin, pruritus, nipple discharges, no
nodules, no new moles, no dry hair and no eczema.
HEENT: She indicates no hear difficulty or tinitus, no congestion, no dental or swallowing
problems and no vision problems with eyeglasses.
Respiratory: She indicates that doesn’t have rinhitis, dysnea, hemoptysis, cough or secretions.
Gastrointestinal: She reports a hiatal hernia, no abdominal pain, no changes in appetite or weight
loss, no changes in elimination frequency or consistency.
Cardiovascular: She indicates that doesn’t have edema, tachycardia, bradycardia, chestmapin,
orthopnea or palpitations.
SOAP Note: Urinary Tract Infection
Identifying Data and Chief Complain
A 20-year-old female single and Hispanic patient comes to the clinic complaining of
urgency and intermittent flow and “pain, burning, fever, blood in urine and low back pain”. She’s
describes the pain and burning as moderate (4) when the symptoms started yesterday morning
with “spots of bleeding in the toilet paper” and the pain progress to severe (7) in the afternoon
with “a lot of red bleeding”. The patient refers that she went to the ER the in the evening and
they administered IV fluids and Toradol I/M for pain. CBC and U/A tests were performed.
Patient says that the pain improved, but all symptoms came back after few hours. No medications
were prescribed for home.
Subjective Symptoms
1. “Progressive and intense pain in low abdomen.”
2. The pain is associated with “burning, fever, chills and blood in urine.”
Subjective Data
Past medical history (PMH): Patient refers frequent migraines and a hiatal hernia. Patient refers
no appetite or weight changes. No other chronic diseases reported.
Family history: Her mother is a 46-year-old woman with migraines and hiatal hernia history.
Mother went under a surgery three weeks ago (lipoma “golf ball size” in left axilla}, no other
chronic diseases reported. Her father is a 54-year-old man with no history of chronic diseases.
Patient’s brother is a 22-year-old man with no history chronic diseases. Grandmother, from
mother’s side, is alive and has hypertension, diabetes mellitus and history of urinary stones. .
Grandfather from mother’s side, had an open heart surgery after a myocardial infarction ten years
ago, he doesn’t has other chronic diseases. She doesn’t have knowledge about her other
grandparents from father’s side health, both are alive.
, CASE STUDY: URINARY TRACT INFECTION
Past social history (PSH): The patient doesn’t smoke or drink alcohol. She’s Catholic. The
patient works part-time in a pizzeria five hours/three days a week. She study the sophomore year
at University of Puerto Rico, Carolina Campus. She goes to the gym three or four times a week
and the others days she “walks a lot at the university”. She states that her diet is high in protein
and fiber, low in carbohydrates and includes lactate: milk, cheese and butter.
Immunization: All vaccines are up to date including Human Papilloma Virus, Varicella and
Influenza (two months ago).
Allergies: No known allergies (NKA).
Surgical history: Never been submitted to a surgery.
Medication history: Patient refers that her gastroenterologist prescribed her Protonix (one a day
½ hour before breakfast) and Carafate (one cap) with each meal every day. She’s refers that “I
never skip a dose”.
Subjective Review of Systems
Constitutional: Patient indicates she has fever, no chills, no weight changes and no fatigue.
Skin: She indicates that doesn’t have lessions, acne dry skin, pruritus, nipple discharges, no
nodules, no new moles, no dry hair and no eczema.
HEENT: She indicates no hear difficulty or tinitus, no congestion, no dental or swallowing
problems and no vision problems with eyeglasses.
Respiratory: She indicates that doesn’t have rinhitis, dysnea, hemoptysis, cough or secretions.
Gastrointestinal: She reports a hiatal hernia, no abdominal pain, no changes in appetite or weight
loss, no changes in elimination frequency or consistency.
Cardiovascular: She indicates that doesn’t have edema, tachycardia, bradycardia, chestmapin,
orthopnea or palpitations.
