This paper presents a clinical SOAP note documenting the assessment and management of a urinary tract infection (UTI) in a 28-year-old woman at 37 weeks gestation. The subjective section details the patient's chief complaints of urinary urgency, dysuria, pelvic pain, and cloudy urine, along with relevant medical, family, and social history. The objective section outlines physical findings and diagnostic criteria, including urinalysis and urine culture results. The assessment confirms a UTI diagnosis, and the treatment plan discusses antibiotic options — including nitrofurantoin and cephalosporins — that are considered safe and effective during pregnancy. Differential diagnoses such as ectopic pregnancy and renal colic are also briefly addressed.
The client is a married, 28-year-old Asian woman who is 37 weeks pregnant. This is her second pregnancy; her first child is alive and living at home with both parents, and she has no history of miscarriage. The client's chief complaint concerns increasing problems with urination.
The client presents with complaints of a constant need to urinate accompanied by a burning sensation. She reports drinking cranberry juice in an effort to alleviate these symptoms but no other self-remedies. The client denies tobacco, alcohol, or illicit drug use.
The findings that emerged from the assessment provide a valid basis for a diagnosis of a urinary tract infection (UTI), which is not uncommon during pregnancy (Sostre & Varma, 2008). A urinalysis can help rule out potential differential diagnoses of ectopic pregnancy or renal colic (Evans & Tippins, 2007), since the symptoms of these conditions can overlap with those of a UTI (Ectopic pregnancy symptoms, 2016; Kidney pain causes, 2016).
Besides a burning sensation when urinating, the client also reports pain in her pelvis, and her urine appears cloudy.
The client's constant need to urinate has caused her to remain at home for the past several weeks. She also reports difficulty resting and sleeping due to the frequency of urination.
The client reports having to urinate more than 20 times a day and vomiting on occasion. Besides pelvic pain, she also reports experiencing occasional pain in her lower left back.
The client's self-restriction to home has adversely affected her social life, including her previously regular weekly restaurant outings with friends. She reports increasing urgency in urination and worsening of the burning sensation in recent weeks.
The client denies experiencing these symptoms during her first pregnancy, which was uneventful. She reports having been hospitalized the previous year to have a broken ankle surgically reduced with a plate after falling on a wet tile floor in the kitchen.
The client has an associate's degree but is currently unemployed, having worked as an administrative assistant at a law firm until the birth of her first child four years previously. Her husband is employed full time as a stockbroker. The family has full coverage health insurance and is financially secure. The client's parents are deceased, but she has two siblings — a brother and a sister — living in China.
The client reports eating little red meat but enjoys fish.
The following review of systems was conducted:
General: Negative for fever, easy fatigability, and chills; positive for weight gain of 5 lbs. in the previous week.
Skin: Negative for pallor, diaphoresis, and rash.
HEENT: Negative for frontal headaches, dizziness, yellowish nasal discharge, post-nasal drip, sore throat, hoarseness, earache, sinus pain, eye discharge, and blurred vision.
Breast: Negative for lumps, masses, or nipple discharge.
Chest/Lungs: Negative for pain on deep inhalation, shortness of breath, chest pain, exertional dyspnea, orthopnea, palpitations, hemoptysis, wheezing, edema, and claudication.
Abdomen: Positive for nausea and vomiting; positive for change in bowel habits.
Genitourinary: Positive for urgency; negative for dysuria, hematuria, and post-menopausal bleeding.
Musculoskeletal: Positive for body malaise, joint stiffness and pain, and weakness; negative for joint swelling.
Neurologic: Negative for confusion, blurred vision, anxiety, paresthesia, slurring of speech, syncope, and unsteady gait.
"Physical examination and urinalysis diagnostic criteria"
"UTI confirmed via urinalysis and urine culture"
"Antibiotic selection and follow-up recommendations"
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