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SoapNote: Urinary Tract Infection

Chief Complain: Pain and gets uncomfortable when urinating,sharp and burning sensation fever-like symptoms.

History of Present Illness: Jane, a twenty-two-year-oldstudent, presented to the hospital complaining of itchiness in hervagina and suspects she has an infection. Previously, she had aproblem with her bladder where she felt a painful ache.

Drug / Medication: Takes painkillers including ibuprofen toease pain.

PastMedical History

Mary has had a history of kidney stones. She has previously beenhospitalized after being diagnosed with an inflammation of thebladder. The abnormality in her urinary tract has resulted in Maryseeking current medical attention to determine if she can address thesame.

Family History

Her mother had been diagnosed with kidney cancer.

Social History

She lives in upcountry with her folks and attends Briton BridgeCollege.

Allergies: None

Eyes: Bluish

Skin: lesions prevalent

Observationsduring Physical Assessment

During the physical assessment, the patient displayed symptoms offever. Her skin was assessed to check for the presence of lesions.The bladder was tender after palpation of the abdomen. She had avaginal discharge that was yellowish in color. She was subjected to apelvic examination where peritoneal inflammation was detected. Herurine was cloudy in appearance.


The following isa probable differential diagnosis for the client presented in thecase alongside its explanation.

  1. Sexually Transmitted Disease

Sexually transmitted infections are those that result when oneengages in intercourse with an individual who has the disease(Echaiz, Cass, Henderson, Babcock, &amp Marschall, 2015). Thepatient could present with vaginal discharge, itchiness at the vaginaor bleeding.

  1. Vaginitis

The condition is characterized by the inflammation of the vagina. Onecan experience a discharge, pain, and itching. In other cases, thepatient is likely to suffer from an irritation of the vulva.

  1. Urethritis

Condition defined by an inflammation of the urethra. Women sufferingfrom the same are likely to experience a frequent urge to urinate(Centers for Disease Control and Prevention, 2012b). They could alsofeel discomfort during urination.

Possible Diagnosis

  1. Urinary tract infection

  2. Vulvovaginitis

  3. Interstitial cystitis


Urinary tract infection- Patients suffering from the conditionexperience an infection at any section of the urinary system. Itcould include the kidney, bladder, kidneys and the urethra. However,most infections occur in the lower urinary tract particularly thebladder and the urethra. Infection of the bladder can be painful, butthe situation can worsen if it spreads to the kidney. Mary presentedto the hospital complaining of pain and itchiness while urinating.She depicted signs of fever that are characteristic of a urinarytract infection. Urinary tract infections are also defined bydysuria and urgency to urinate (Gebäck, Hansson, Martinell,Sandberg, Sixt, &amp Jodal, 2015). This is the most appropriatediagnosis for the patient. The condition is common especially amongwomen compared to men (National Institutes of Health, 2012). It couldexplain the reason why Mary could be suffering from the condition.

Treatment Plan and Management

A treatment plan should focus on helping Mary learn how to manage thecondition. The plan would entail educating Mary, and prescribingmedication to help in the management.


I will focus on educating Mary on the need to exercise proper hygieneto help in curbing the condition. However, I will explain thediagnosis while at the same time suggesting the appropriatemedication and reassure her of the high possibility of getting cured.

Medical Management

Since she is having an inflammation of the bladder, it is appropriatethat she takes trimethoprim for three days. Further, she can takephenazopyridine at quantities of 100 to 200 mg for 48 hours. Then,for the next 14 days, an antibiotic would help.

Surgical Management

It would be appropriate to employ surgical treatment uponascertaining the structure of the urinary tract is affected.

Education Strategies

It is essentialthat the patient sticks to the prescribed medication.

Observecleanliness and hygiene

Frequent medicalcheckups to monitor the condition.


I would advise that the patient sticks to the recommended medicationand watch out for any changes. Considering that it is a urinary tractinfection, I would reiterate the need for the patient to focus onupholding high standards of hygiene. I would remind her to seekcounseling support to help her cope with the distressful condition.


Centers for Disease Control and Prevention. (2012b). Women’shealth. Retrieved from

Echaiz, J. F., Cass, C., Henderson, J. P., Babcock, H. M., &ampMarschall, J. (2015). Low correlation between self-report and medicalrecord documentation of urinary tract infection symptoms. Americanjournal of infection control, 43(9), 983-986.

Gebäck, C., Hansson, S., Martinell, J., Sandberg, T., Sixt, R., &ampJodal, U. (2015). Renal function in adult women with urinary tractinfection in childhood. Pediatric Nephrology, 30(9),1493-1499.

National Institutes of Health. (2012). Office of Research on Women’sHealth (ORWH). Retrieved from

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