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.
S: The patient is a 27-year-old female who presents with dysuria, nocturia, and hypogastric abdominal pain. She denies fever, chills, and vomiting. The patient is a college student doing her masters and lives with her parents. She denies any past medical history, tobacco, alcohol, or illicit drug use, including marijuana. She reports being in a stable relationship with her partner for the past four years and using condoms during sexual activity.
O: Vital Signs: Blood pressure 118/78 mmHg, heart rate 76 bpm, respiratory rate 14 bpm, temperature 98.4°F. General: The patient appears comfortable and in no acute distress. HEENT: Head is normocephalic and atraumatic. Eyes, ears, nose, and throat are unremarkable. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no masses or hepatosplenomegaly. Genitourinary: External genitalia normal. Vaginal exam shows no discharge or lesions. Urine dipstick shows high concentration of nitrites and leukocytes. Musculoskeletal: No joint swelling or deformity. Neurological: Cranial nerves II-XII grossly intact.
- Urinary tract infection (UTI) – based on the patient’s symptoms, urinalysis results, and high concentration of nitrites and leukocytes on urine dipstick.
- Pyelonephritis – a possible differential diagnosis due to the patient’s hypogastric abdominal pain and dysuria; however, the absence of fever, flank pain, and vomiting makes this less likely.
- Interstitial cystitis – a possible differential diagnosis due to the patient’s dysuria and nocturia; however, this diagnosis is less likely given the patient’s young age and absence of other risk factors.
P: The patient is prescribed Macrobid 100 mg twice a day PO for ten days. The patient is advised to drink plenty of water, avoid spicy food, and clean the urethral external part with light soap and water. The patient was advised to abstain from sexual activity for the next week. The patient is advised that urine can turn yellow when taking the medication. The patient will return to the office in four weeks or earlier if the problems worsen. A urinalysis with culture will be performed two weeks after finishing the antibiotic.
- American Urological Association. (2019). Diagnosis and Treatment of Acute Uncomplicated Cystitis. https://www.auanet.org/guidelines/acute-uncomplicated-cystitis-guideline
- Hanno, P. M., Erickson, D., Moldwin, R., Faraday, M. M., American Urological Association, & Interstitial Cystitis Association. (2011). Diagnosis and treatment of interstitial cystitis/bladder pain syndrome: AUA guideline amendment. Journal of Urology, 185(6), 2162-2170.
- NICE. (2019). Urinary tract infection (lower): antimicrobial prescribing. https://www.nice.org.uk/guidance/ng109