SOAP Note 4: R.T., Age 29, Female, Subjective CC

SOAP NOTE 4 Name: R.T Date: Age: 29 Sex: F SUBJECTIVE CC: “I am urinating all the time, and it burns when I urinateâ€

This is a 29-year-old African American woman presenting with complaints of dysuria, urgency, frequency of urination, foul-smelling urine, mild fever, and symptoms exacerbated by physical and emotional stress. She uses spermicide-coated condoms for contraception and reports recent sexual activity. No chronic illnesses or past surgeries are noted. Family history includes a father with cardiac disease; no significant social or medication allergies reported. Objective findings include suprapubic tenderness, cloudy urine with leukocyte esterase, nitrites, bacteria, and slight hematuria. Physical exam shows no skin lesions, normal HEENT, lungs clear, abdomen soft, and pelvis unremarkable aside from tenderness over the bladder base. Laboratory testing confirms a urinary tract infection consistent with cystitis. The patient is diagnosed with unspecified cystitis and treated with antibiotics and education on symptom management.

Paper For Above instruction

The case of a 29-year-old woman presenting with symptoms indicative of cystitis underscores the importance of comprehensive assessment and targeted management of urinary tract infections (UTIs) in women. UTIs are among the most common bacterial infections encountered in primary care, especially in women due to anatomical predisposition such as a shorter urethra and closer proximity of the urethral opening to the anus. Recognizing the clinical presentation and appropriate diagnostic workup ensures prompt treatment, reducing the risk of complications such as pyelonephritis or recurrent infections.

The patient's subjective complaints of dysuria, urgency, frequency, foul-smelling urine, and mild fever align with classic signs of lower urinary tract infection, particularly cystitis. Her history of recent sexual activity and use of spermicide-coated condoms is significant, as sexual activity is a known risk factor for UTIs, with spermicides potentially disrupting vaginal flora and facilitating bacterial colonization (Foxman, 2014). Her reported stress-related exacerbation may also influence immune response, contributing to symptom severity, although it does not directly cause the infection.

The physical examination findings, including suprapubic tenderness and bladder base tenderness, support a diagnosis of cystitis. Laboratory investigations such as urinalysis and urine culture are critical in confirming the diagnosis. The urinalysis in this case demonstrated cloudy urine with positive leukocyte esterase and nitrites, elevated white blood cell count, bacteria, and trace hematuria—findings characteristic of bacterial cystitis. Urinalysis's sensitivity and specificity for UTIs make it a cornerstone in diagnosis, although urine culture remains the gold standard for pathogen identification and antibiotic sensitivities (Hooton, 2012).

Management of uncomplicated cystitis involves antimicrobial therapy, symptomatic relief, and patient education. Nitrofurantoin, 100 mg twice daily for five days, was chosen due to its efficacy for uncomplicated lower UTIs and minimal systemic side effects (Gupta et al., 2011). Patient education focused on avoiding bladder irritants such as caffeine, spicy foods, artificial sweeteners, and alcohol, which can aggravate symptoms. Hydration and physical comfort measures like warm sitz baths are non-pharmacological adjuncts that can ease discomfort. The importance of completing the full course of antibiotics and follow-up care was emphasized (Nicolle, 2014).

Furthermore, counseling about preventive measures is vital. Behavioral modifications such as proper perineal hygiene, urinating after sexual intercourse, and avoiding irritants can reduce recurrence. Since recurrent UTIs are common in women, further assessment might be necessary if symptoms persist or recur frequently (Dielubanza & Schaeffer, 2019). In this context, the patient’s use of spermicides warrants reconsideration, and alternative contraceptive options that do not increase UTI risk could be discussed.

In conclusion, the successful management of this case relies on accurate diagnosis, appropriate antibiotic therapy, patient education, and preventive strategies. Addressing UTIs effectively improves patient outcomes, minimizes complications, and reduces healthcare costs associated with recurrent infections. As evidenced in current guidelines, tailored treatment based on the severity, patient history, and local antimicrobial resistance patterns is essential for optimal care (Croxford et al., 2010).

References

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