Write a SOAP note for a 30-year-old otherwise healthy female with dysuria, urinary frequency, urgency, and suprapubic discomfort for two days, no fever, flank pain, hematuria, or vaginal discharge, and urinalysis positive for leukocyte esterase, nitrites, and >10 white blood cells per high-power field (HPF).

SOAP Note for Uncomplicated Acute Cystitis

Subjective

Chief Complaint: Dysuria, urinary frequency, and urgency for 2 days

History of Present Illness:

• 30-year-old female presenting with 2-day history of:
  • Dysuria (painful urination)
  • Urinary frequency
  • Urgency
  • Suprapubic discomfort
• Negative symptoms (critical for uncomplicated classification):
  • No fever
  • No flank pain
  • No hematuria
  • No vaginal discharge
• No recent antibiotic use
• Sexual history and contraceptive use (document if spermicide use, new partner—risk factors for UTI)
• Last menstrual period
• Previous UTI history

Objective

Vital Signs: Afebrile, hemodynamically stable

Physical Examination:

• General: Well-appearing, no acute distress
• Abdomen: Suprapubic tenderness present, no costovertebral angle tenderness
• Pelvic: No vaginal discharge noted (absence of discharge increases UTI likelihood) 1

Urinalysis:

• Leukocyte esterase: Positive
• Nitrites: Positive
• WBCs: >10/HPF
• Note: The combination of positive nitrites and leukocyte esterase increases UTI probability >7-fold 1

Assessment

Uncomplicated acute cystitis

This is a straightforward diagnosis of uncomplicated cystitis based on the classic triad of dysuria, frequency, and urgency in a nonpregnant woman without anatomic/functional urinary tract abnormalities or comorbidities 2. The absence of fever, flank pain, and vaginal discharge, combined with positive urinalysis findings (both nitrites and leukocyte esterase), confirms the diagnosis with high probability 1, 3.

Key diagnostic reasoning:

• The focused history of lower urinary tract symptoms (dysuria, frequency, urgency) without vaginal discharge allows diagnosis with high probability 2
• Positive nitrites increase UTI probability >5-fold; moderate pyuria increases it >1.5-fold; both together increase probability >7-fold 1
• Urine culture is NOT indicated in this uncomplicated presentation 2

Common pitfall avoided: This patient does NOT need a urine culture because she has typical symptoms, no complicating factors, and this is not a recurrent infection 2. Cultures are only indicated for suspected pyelonephritis, symptoms not resolving/recurring within 4 weeks, atypical symptoms, or pregnancy 2.

Plan

Antibiotic Treatment

First-line options per 2024 EAU guidelines 2:

• Nitrofurantoin 100 mg twice daily for 5 days (preferred)
• OR Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%)
• OR Fosfomycin trometamol 3g single dose
• OR Pivmecillinam for 5 days

Alternative consideration: For mild-to-moderate symptoms, symptomatic therapy with ibuprofen may be discussed as an alternative to antibiotics in consultation with the patient 2. However, given this patient's 2-day symptom duration and positive urinalysis, antibiotic therapy is appropriate.

Patient Education

• Complete full antibiotic course even if symptoms improve
• Symptoms should resolve within 2-3 days
• Increase fluid intake
• Avoid bladder irritants (caffeine, alcohol, spicy foods)

Follow-up

• No routine post-treatment urinalysis or culture needed if asymptomatic 2
• Return if:
  • Symptoms worsen or fail to improve within 48-72 hours
  • Fever, flank pain, or vomiting develop (suggests pyelonephritis)
  • Symptoms recur within 2 weeks
• If symptoms persist or recur within 2 weeks: obtain urine culture and susceptibility testing, retreat with 7-day course of different antibiotic 2
• If symptoms recur within 4 weeks: obtain urine culture before retreatment 2

Prevention Counseling

• Post-coital voiding if sexually active
• Avoid spermicide use
• Adequate hydration
• Consider prophylaxis only if develops recurrent UTIs (≥3 infections/year or 2 infections/6 months)

Critical distinction: This patient's acute onset of symptoms over 2 days distinguishes UTI from overactive bladder, which presents with chronic symptoms 4. The presence of dysuria further supports UTI over OAB, as dysuria is not a feature of OAB 4.