SOAP Note for a Patient with Dysuria

Running head: DYSURIA
Dysuria
Name of the student:
Name of the University:
Author’s note

1DYSURIA
SOAP note for a patient with dysuria
S (Subjective): A 35 year old male patient came to the acute care unit with complains of pain
during urination. The patients reported about urgency to urinate and getting troubled by pain at
the end of urination.
O (Objective): The review of lab test results revealed a positive urine culture evidenced by high
predictive value of nitrite in the urine sample. The PV value was 80% which indicates a highly
positive test. The number of leukocyte was more than the normal range and this also indicated an
abnormal urinalysis test results.
A (Assessment): Based on the review of urinalysis test results, it can be said that the patient is
suffering from urinary tract infection which had led to dysuria. The patient might have immune-
comprised status or functional abnormalities of the urinary tract thus leading to the diagnosis of
dysuria. This type of urinary tract infection occurs because of bladder muscle contraction and
peristalsis thus causing urine to come in contact with inflamed mucosa (Mehta & Reddivari,
2019).
P (Plan): It is planned to conduct additional laboratory testing such as blood culture and
complete blood count test. It is also planned to implement antibiotic therapy. Patient medication
history and local resistance patterns need to be reviewed before selecting the antibiotics (Michels
& Sands, 2015).