Posted: April 24th, 2025

Soap 1

Create a soap note based on this patient and use the template provided. 

35-year-old female patient who presented with flank pain and difficulty urinating. The primary challenge was differentiating between several potential diagnoses that shared overlapping symptoms. However, the success of this case lay in developing a comprehensive plan of care based on a thorough assessment and evidence-based guidelines. 

To begin, the patient exhibited symptoms including right-sided flank pain that radiated to the lower abdomen, dysuria, increased urinary frequency, a low-grade fever of1 00.6 F, nausea without vomiting, and mild costovertebral angle tenderness. The assessment process involved taking a detailed history, conducting a physical examination, and ordering laboratory tests such as urinalysis, urine culture, and complete blood count. An abdominal ultrasound was also performed to check for possible kidney stones or other structural abnormalities. 

Three differential diagnoses were considered. The first was urinary tract infection (UTI), which was deemed the most likely diagnosis due to the presence of dysuria, frequency, and low-grade fever. UTIs are common in women of reproductive age and can present with these symptoms (Medina & Castillo-Pino, 2019). The second possibility was pyelonephritis, considered due to the flank pain and fever, indicating an upper UTI that may have ascended to the kidneys. The third differential diagnosis was nephrolithiasis (kidney stones), given the acute onset of flank pain, however, the absence of severe colicky pain made this less likely. 

The plan of care involved antibiotic therapy pending culture results to treat the suspected UTI. Moreover, pain management included NSAIDs to alleviate discomfort. The patient was also advised to increase fluid intake to help flush out any infection and prevent dehydration. A follow-up appointment was then scheduled for 72 hours later to monitor symptom improvement and adjust treatment, if necessary, based on culture results.  

Health promotion interventions for this patient focused on educating her about proper hygiene practices to prevent future UTIs, advising on adequate hydration, discussing sexual health practices that may reduce UTI risk, and encouraging regular health check-ups and prompt reporting of any urinary symptoms. 

• Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
• You must use the template provided. Turnitin will recognize the template and not score against it.
• Your submission will be reviewed for plagiarism through Turnitin.

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

General:
HEENT:
Neck:
Lungs:
Cardio
Breast:
GI:
M/F genital:
GU:
Neuro
Musculo:
Activity:
Psychosocial:
Derm:

Signature (with appropriate credentials):_____________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])