Nursing Soap Note on Urinary Tract Infection (UTI)

Urinary Tract Infection SOAP Note

SUBJECTIVE:
PATIENT INFORMATION
ID: Patient JT DOB 8 TH JULY 1982, 40 years old, presents to the clinic in the company of
husband today. Patient is a reliable historian. The patient is 22-weeks pregnant.
CC: “I feel pain on urinations. I can feel the itchiness around my private parts.”

HISTORY OF PRESENT ILLNESS (HPI): Patient presents to the clinic with complaints of
pain and itchiness during urination. She reports to have experienced the above symptoms for two
weeks. The patient reports that it started as itching at the early stages. The itching increased with
time and pain accompanied it. She reports that pain is felt mostly during urination with a burning
sensation. There is however no traces of blood during urination. She reports a change of color for
urine however.

PAST MEDICAL HISTORY:
The patient was hospitalized after a RTA that had her dislocate her hip bone. Later the patient
was discharged after healing from the hip replacement surgery and being stable.
In the first trimester, the patient was diagnosed of iron deficiency anemia. The patient had been
brought to the facility after episodes of fatigue and after running a full blood count, the HB levels
were quite low. The patient was put on iron supplements and vitamin B12 supplements in

addition to the folates. Dexamethasone was also administered to facilitate faster maturation of
the fetus.
Surgical History/Hospitalizations:
Patient was admitted 5 years ago following trauma from RTA
Patient has a history of hip replacement surgery following RTA.
The patient was transfused 3 points of blood at that time.

MEDICATIONS:
 Folic acid
 B12
 Ibuprofen
 Dexamethasone
ALLERGIES:
The patient reports having allergy to Sulphur products and medications.
FAMILY HISTORY:
History of cancer of the bladder in the family. The grandmother died of cancer of the bladder.
SOCIAL HISTORY
JT is a farmer who is married to one husband and has two male children. Sexually she is
heterosexual.
The family feeds on a balanced diet. Most of their consumptions come from their garden.
IMMUNIZATIONS:
Seasonal Influenza and
Pfizer COVID vaccine

Tetanus Toxoids
REVIEW OF SYSTEMS
CONSTITUTIONAL: The patient reports pain and burning sensation during urinations. Denies
decreased appetite, weight loss, fever, or chills
NEUROLOGIC: denies dizziness, headache, lightheadedness
HEENT: well groomed. No growth on head or deformity.
Eyes: denies pain, or blurry vision
Ears: denies any discharge, ringing ears, pain
Nose: Denies breathing difficulty
Throat: denies problem with swallowing
RESPIRATORY: denies tachypnea, breathing difficulties, nasal blockage, denies cough,
wheezing, or difficulty breathing.
CARDIOVASCULAR: denies chest pain, racing heartbeat, or shortness of breath.
Denies tachycardia, bradycardia, pounding beats, mental confusion.
GASTROINTESTINAL: denies constipation and gastrointestinal irritation.
GENITOURINARY: The reports experiencing urinary discomfort and itching, pain on
urination, burning sensation
MUSCULOSKELETAL: Denies dermatitis, skin infections.
SKIN: asserts having clear skin, denies erythema
OBJECTIVE
VITAL SIGNS: P:75 beats/min BP:128/74 RR: 19 T: 36.8 0 C SpO2 RA: 97% Pain : 6/10
Ht : 172cm Wt : 73kg

PHYSICAL EXAM
GENERAL APPREARANCE: Generally weak. Sick looking.
NEUROLOGIC: The patient is well oriented to time, place, and the people around them.
HEENT: The hair that sits on top of one's head is styled to absolute perfection. There was no
evidence of either head growth or head trauma that could be found.
Eyes are bilaterally equal
Symmetry of the ears with no discharge
Nose: flawlessly even and symmetrical, with a distinct channel running down the middle. No
sneezing, please.
Throat: clear with ease of swallowing.
Lips are pink and moist
N jugular distention
CARDIOVASCULAR: normal heart rate on auscultation and a S1 and S2 are heard, and no
abnormal sounds
RESPIRATORY: No tachypnea and hyperventilation. There is no stuffiness in the nose.
Normal breathing patterns and lungs that sound healthy. There were crackles.
GASTROINTESTINAL: Dullness, clear bowel sounds no abdominal distention,
MUSKULOSKELETAL: no joint pains, and ROM in normal parameters. No fractures
INTEGUMENTARY: clear skin with no erythema, no damage to the skin.
Assessment:
Both the woman and her partner complained