Example of Assessment in SOAP for Urinary Tract Infection
The assessment for a patient presenting with urinary tract infection symptoms should clearly identify the type of UTI (uncomplicated vs. complicated), infection location (cystitis vs. pyelonephritis), and any risk factors requiring special consideration. 1
Core Components of UTI Assessment
1. Classification of UTI
- Uncomplicated UTI: Healthy non-pregnant woman with normal urinary tract
- Complicated UTI: Present in men, pregnancy, anatomical abnormalities, catheterized patients
- Recurrent UTI: ≥2 episodes in 6 months or ≥3 episodes in 12 months
- Location of infection:
- Cystitis (bladder): Localized symptoms (dysuria, frequency, urgency)
- Pyelonephritis (kidney): Systemic symptoms (high fever, malaise, vomiting, flank pain)
2. Diagnostic Confirmation
- Urinalysis findings: Positive leukocyte esterase, nitrites, hematuria, pyuria
- Urine culture results: Single organism growth meeting threshold criteria:
- Clean-catch midstream: >10^5 CFU/mL
- Catheterized specimen: >10^3-10^5 CFU/mL
- Suprapubic aspiration: >10^2 CFU/mL or any growth
- Organism identification: E. coli most common (also consider Klebsiella, Enterococcus, Pseudomonas, Staphylococcus) 1, 2
3. Risk Factors Assessment
- Recurrence risk factors: Prior UTI history, sexual activity, anatomical abnormalities
- Complication risk factors: Pregnancy, diabetes, immunosuppression, urinary tract abnormalities
- Malignancy risk factors: Age ≥35 years, tobacco use, chemical exposures, history of pelvic radiation, exposure to cyclophosphamide 1
Sample SOAP Assessment
"Assessment: 42-year-old female with acute uncomplicated cystitis based on 2-day history of dysuria, urinary frequency, urgency, and suprapubic discomfort. Urinalysis shows positive leukocyte esterase, nitrites, and microscopic hematuria, consistent with bacterial UTI. Most likely pathogen is E. coli based on epidemiology. No fever, flank pain, or systemic symptoms to suggest pyelonephritis. No risk factors for complicated infection (non-pregnant, no anatomical abnormalities, no recent catheterization). This represents her first UTI episode, so not classified as recurrent. Given her age >35 and smoking history, will monitor for complete symptom resolution to rule out underlying urinary tract pathology that might require further evaluation."
Key Considerations in Assessment
- Avoid overdiagnosis: The American Geriatrics Society recommends against UTI diagnosis based solely on positive urine culture without symptoms, especially in elderly patients 1
- Distinguish from other conditions: Consider sexually transmitted infections or vaginitis in women with external dysuria 3
- Antibiotic selection: Consider local resistance patterns when selecting empiric therapy; E. coli remains predominant pathogen but increasing resistance to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole 1, 3
- Follow-up planning: Include assessment of need for follow-up urinalysis after treatment completion to confirm resolution 1
Common Pitfalls to Avoid
- Asymptomatic bacteriuria: Avoid diagnosing UTI based solely on positive culture without symptoms 1
- Multiple organisms: Generally indicates contamination rather than true infection 1
- Incomplete assessment: Failing to distinguish between cystitis and pyelonephritis, which require different treatment approaches
- Missing complications: Not identifying risk factors that would classify the UTI as complicated and potentially require longer treatment duration or different antibiotics 1, 4
Remember that clinical cure (symptom resolution) is expected within 3-7 days after initiating appropriate antimicrobial therapy 1.