What is an example of an assessment in SOAP for a patient presenting with symptoms of a urinary tract infection?

Example of Assessment in SOAP for Urinary Tract Infection

The assessment section of a SOAP note for a patient with UTI symptoms should clearly identify the diagnosis as "Acute Uncomplicated Urinary Tract Infection" with specific findings that support this diagnosis, including dysuria, frequency, urgency, and positive urinalysis findings. 1

Key Components of UTI Assessment

Diagnostic Criteria to Include:

• Symptoms assessment:

  • Presence of localized symptoms (dysuria, frequency, urgency, suprapubic pain)
  • Absence or presence of systemic symptoms (fever, chills, flank pain)
  • Abrupt onset of symptoms
  • Voiding small volumes
  • Presence of hematuria (occurs in ~50% of bacterial cystitis) 2

• Physical examination findings:

  • Suprapubic tenderness
  • Presence/absence of costovertebral angle tenderness (to differentiate cystitis from pyelonephritis)
  • Vital signs (particularly temperature to assess for fever)

• Laboratory findings:

  • Urinalysis results: leukocyte esterase, nitrites, pyuria (≥10 WBCs/high-power field), hematuria 1
  • Urine culture results if obtained (organism and susceptibility)
  • Presence of significant bacteriuria (>10^5 CFU/mL for clean-catch specimens, or >10^3 CFU/mL for catheterized specimens) 1

Differential Diagnosis Considerations:

• Acute uncomplicated cystitis
• Acute pyelonephritis (if fever, flank pain present)
• Sexually transmitted infections
• Vaginitis
• Interstitial cystitis
• Urinary stone disease

Sample Assessment Format:

Assessment: 
1. Acute uncomplicated urinary tract infection (cystitis) as evidenced by:
   - Acute onset dysuria, urinary frequency, and urgency for 2 days
   - Positive leukocyte esterase and nitrites on urinalysis
   - Pyuria (15-20 WBCs/HPF)
   - Absence of fever, flank pain, or systemic symptoms
   - No recent antibiotic use or history of resistant organisms

2. Risk factors for current infection:
   - History of previous UTI 6 months ago
   - Sexual activity (new partner)
   - Inadequate fluid intake

3. No evidence of complicated infection:
   - No fever or flank pain suggesting pyelonephritis
   - No anatomical abnormalities
   - No pregnancy
   - No immunocompromise
   - No indwelling catheter

Important Distinctions to Include

Uncomplicated vs. Complicated UTI:

• Identify if this is an uncomplicated UTI (healthy non-pregnant woman with normal urinary tract) or complicated UTI (men, pregnancy, anatomical abnormalities, catheter, etc.) 3
• Note if this is recurrent UTI (≥2 episodes in 6 months or ≥3 episodes in 12 months) 3

Cystitis vs. Pyelonephritis:

• Cystitis: Limited to bladder with localized symptoms (dysuria, frequency, urgency) 3
• Pyelonephritis: Infection of kidneys with systemic symptoms (high fever, malaise, vomiting, flank pain) 3

Common Pitfalls to Avoid

1. Misinterpreting asymptomatic bacteriuria as UTI:

   • Avoid diagnosing UTI based solely on positive urine culture without symptoms, especially in elderly patients 3, 1
   • The Infectious Diseases Society of America recommends against treating asymptomatic bacteriuria except in specific circumstances 1

2. Overlooking alternative diagnoses:

   • UTI symptoms can overlap with STIs and vaginitis 2
   • Consider these alternatives when symptoms don't align perfectly with UTI

3. Failing to distinguish between upper and lower tract infections:

   • Clearly document presence/absence of fever, flank pain, and systemic symptoms to differentiate cystitis from pyelonephritis 3

4. Not addressing recurrence risk:

   • Include assessment of risk factors for recurrence in your assessment to guide preventive strategies 1

By following this structured approach to the assessment section of your SOAP note, you'll provide a comprehensive evaluation that supports appropriate treatment decisions and follow-up care for patients with UTI symptoms.