SOAP Note: Dysuria and Clinical Practice Guidelines Analysis

This assignment presents a SOAP (Subjective, Objective, Assessment, Plan) note for an 18-year-old female patient complaining of dysuria and lower abdominal cramping. The note details the patient's history of present illness, medical conditions, medications, and allergies. The objective section includes a physical examination with vital signs and findings from various systems. Diagnostic testing includes a pelvic exam, urine test, and swabs. The assessment concludes the patient likely has acute dysuria and highlights social risk factors. The plan involves treatment regimens similar to those for related conditions. The assignment includes a critique of other SOAP notes and reflections on areas for improvement. References to relevant medical literature are included.

Running head: SOAP 1
Soap Notes and Clinical Practice Guidelines
Name of Student
School

Soap Notes and Clinical Practice Guidelines
Subjective
The chief complainant is an 18-year-old female who mainly complains of "I have been
having dysuria and lower abdominal cramping."
History of current illness: the patient has been having such complications for the last five
days. However, these complications have been asymptomatic though. The patient has not
undergone severe illness and surgery lately.
Medical condition: Dysuria
Medications: None
Allergies: None
Regular cycles 3-4/28 cramping present.
Objective
Physical Examination
General Appearance: The lady was well developed and alert
Vital signs: wt. 175lob. Ht. 5’4’, temp 98.9, RR, 87, P. 18, HR, 70, BP 120/77
Eyes: Patient had a white sclera and pink conjunctiva; all the pupils were round and qual.
Ear, nose, mouth, and throat: Ears had no lesion, denies any discharge, no redness, had no
swelling, the patient had no hearing difficulties. Nose; had mucus had no inflammation, denies

any lesion. Mouth: was pink and moist, had well maintained dental hygiene, throat: denies
inflammation, tonsils were WNL denied erythema, had no masses.
Gastrointestinal: Patient has abdominal pain, abdomen soft and tender, denies bloat, had
no constipation
Genitourinary: Had no palpation, the external genitals were healthy, had no lesion, her
vaginal was normal and appeared healthy, her cervix was healthy and had no injury, last smear
test results revealed a healthy cervix.
Neurologic: The lady was oriented, cooperative, and had a sharp touch sense.
Psychiatric: Was able to express her appropriately, had proper judgment.
Diagnostic Testing
A pelvic exam will be conducted to test for the presence of Dysuria. Furthermore, we
shall check for tenderness around the kidneys in addition to the test done on the genitals. A urine
test will also be done to test for bladder infections in our patients. Also, a swab will be tasted in
the case of urethritis and vaginitis (Michels, Sands & Sands, 2015). Lastly, we shall take urine
samples for testing in the laboratory to determine whether the patent has kidney infections.
Assessment
Having such a comprehensive and thorough physical examination, system, and laboratory
examination, several conclusions were developed. First, the lady appeared to be having acute
Dysuria. Additionally, she presented a social history that had very significant risk factors for

Dysuria, as indicated by Heytens et al. (2017). She also says she has abdominal pains. The
patient also notes that she has had an active sexual relationship over the past month. For the
above-provided analysis of the symptoms and reports provided, some differential diagnoses were
given, which include, testing of urine samples, swab tests, and pelvic exams.
Plan
Acute Dysuria is the earliest stage of Dysuria. At this stage, patients do not show any
symptoms of the diseases. Thus, patients appear normal, and hence, a person is said to be at the
acute stage of Dysuria. Infections to the internal genital structures are the major causes of
Dysuria in the United States (Jenkins, 2016). Since this is undeveloped Dysuria, a treatment
regimen that will be appropriate is similar to that of dysplasia of the cervix. Other approaches
used include those applied for vaginitis, urethritis, and cystitis and pyelonephritis (King, 2019).
Critique
Jessie and Finnie recently posted their Soaps. Interestingly, their soaps had no critical
physical assessment of their patient. Besides, it lacked depth and was overly shallow. One area I
need growth is during the writing of soaps. I need more exercise and practice to write better. I
am, however, encouraged that my strengths lie in carefully listening to patients.

References
Heytens, S., De Sutter, A., Coorevits, L., Cools, P., Boelens, J., Van Simaey, L., ... & Claeys, G.
(2017). Women with symptoms of a urinary tract infection but a negative urine culture:
PCR-based quantification of Escherichia coli suggests infection in most cases. Clinical
Microbiology and Infection, 23(9), 647-652.
Jenkins, L. (2016). Sexual health and dysuria. Essential Primary Care, 219.
King, C. R. (2019). Common Causes, Diagnostic Evaluation, and Treatment in Women.
In Pain (pp. 845-849). Springer, Cham.
Michels, T. C., Sands, J. E., & Sands, J. E. (2015). Dysuria: Evaluation and Differential
Diagnosis in Adults. American family physician, 92(9).