SOAP Note

Date: October 17, 2022

Time: 15:00

Subjective:

Demographics: 42-year-old Caucasian female

CC: “It burns when I urinate. I am urinating all the time.”

HPI: GS is a 42-year-old Caucasian woman presenting to a family medicine clinic with

complaints of dysuria, urinary frequency and urgency, and suprapubic tenderness for the past 2
days.

PMH:
 Patient has been previously diagnosed with three UTIs over the past 8 months based on
symptoms. Her last UTI was 1 month ago. Each episode was treated with oral
TMP/SMX.
 Hypertension
 Anxiety

Medications:
Medication Dose Route Frequency Indication
Metoprolol tartrate 50mg By mouth Twice daily Hypertension?
Sertraline 50mg By mouth Once daily Anxiety

FH:
 Mother has Type 2 diabetes mellitus

SH:
 Denies smoking but does admit to occasional marijuana use
 Social alcohol use
 Sexually active with one partner for last 9 months, uses spermicide-coated condoms for
contraception

Allergies: Amoxicillin – GI upset

Objective:

ROS:
 Patient reports urethral pain and burning with urination, as well as mild suprapubic
tenderness. She denies systemic symptoms such as fever, chills, vomiting, or back pain,
and does not report any urethral or vaginal discharge. Upon further questioning, she notes
that the UTIs started soon after she met her new boyfriend, and she does not always
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 completely empty her bladder after sexual intercourse. GS also noted that she stopped
taking her sertraline around the time she started dating her new boyfriend because she
noticed that she wasn’t as into intercourse as she used to be and now is. She has not
restarted it.

Gen: Cooperative woman in no acute distress

Skin: No skin lesions

Back: No CVA tenderness

Abd: Soft; (+) bowel sounds; no organomegaly or tenderness

Pelvic: No vaginal discharge or lesions; LMP 2 weeks ago; mild suprapubic tenderness

Vitals:
Height 5’5”
Weight 57 kg
BP 134/82 mmHg
Temp 36.8°C
HR 68 bpm
RR 16 breaths/min

Labs:
Result Reference Range
Serum Chemistry
Na 141 135-145 mEq/L
K 3.9 3.5-5.0 mEq/L
Cl 99 96-109 mEq/L
CO2 27 23-29 mEq/L
BUN 20 8-20 mg/dL
SCr 0.8 0.6-1.2 mg/dL
Glucose 78 80-120 mg/dL
Hemoglobin A1C 5.3 < 7%
Hematology
Hgb 13.9 11.6-15 g/dL
Hct 40.6 36-48%
Plt 275 150000-450000
WBC 22.3 4000-11000
PMN 80 55-70%
Bands 13 0-5%
Lymphocytes 7 25-35%
Monocytes 0 2-6%

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 Parameter Result
Hepatic
Bilirubin (mg/dL) 0.2
Alkaline Phosphatase (Units/L) 48
Alanine Transaminase (Units/L) 20
Aspartate Transaminase 22
(Units/L)
Urinalysis
Appearance Cloudy
Color Yellow
pH 5.0
Blood Trace
Ketones Negative
Leukocyte esterase Positive
Nitrites Positive
Urine protein, qualitative Negative
Urine glucose, qualitative Negative
WBC/hpf 50
RBC/hpf 1-5
Bacteria Many

 Additional pertinent labs:

o CrCl: 82.4 ml/min
o IBW: 57kg

Assessment:
 Problem 1: Acute Uncomplicated Cystitis
o Goal of therapy
 Prevent or treat systemic consequences of infection
 Select a treatment that is patient specific and has low toxicities
 Minimize antimicrobial resistance
 Prevent recurrence of infection
 Eradicate causative pathogen
 2010 IDSA Guidelines for the Treatment of Acute Uncomplicated
Cystitis and Pyelonephritis in Women
o Discussion of subjective and objective information
 Patient was diagnosed with Acute uncomplicated cystitis, this is the third
occurrence of a urinary tract infection (UTI) over the past 8 months,
with her last one being 1 month prior. Due to the fact that the patient has
experienced 3 UTI’s in the past year, this would be considered a
recurrent UTI. The patient has been seeing her current boyfriend for 9
months and they typically use spermicidal condoms to prevent
pregnancy, which are known to interrupt the vaginal pH. The three risk

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 main risk factors for a UTI are being female and sexually active, the use
of spermicides, and incomplete voiding. GS also admitted that she does
not always completely empty her bladder after sexual intercourse. Thus,
this patient meets all three risk factors for developing a UTI. The patient
is experiencing symptoms of dysuria, urinary frequency and urgency,
and suprapubic tenderness for the past 2 days which are the hallmark
symptoms of a lower urinary tract infection, meaning it has not
progressed to her kidneys. The patient was previously treated with oral
Sulfamethoxazole/Trimethoprim, to which she did not complain of any
complications. The patients family history does not display any
predispositions for recurrent UTIs. She also was not in distress and her
physical examination appeared normal. GS’s serum chemistry values are
all within range however her hematology report did show some
deviances from the normal values. This includes her Bands (13%) and
Lymphocytes (7%), which are indicative of bacterial infection. The
patients hepatic and renal function also appeared normal. It is also
evident that the urinalysis report shows some abnormalities, as the urine
appears cloudy and yellow. The urinalysis was also positive for nitrites
and leukocyte esterase’s which are also indicative of infection. Finally,
there are many bacteria present which helps solidify that she is
experiencing a UTI.
o Treatment Considerations
 Per the 2010 IDSA Guidelines for the Treatment of Acute
Uncomplicated Cystitis and Pyelonephritis in Women, the first line
options for the treatment of acute uncomplicated cystitis in the absence
of fever, flank pain, or other suspicions for pyelonephritis, are
nitrofurantoin, trimethoprim/sulfamethoxazole (TMP/SMX), and
fosfomycin.
 GS has previously been treated in the past 3 months using TMP/SMX,
therefore it is in her best interest to try a different antibiotic this time.
Therefore, the first line option for GS is Nitrofurantoin, this is because it
has minimal resistance to bacteria and has excellent efficacy for acute
complicated cystitis.
 The second option for GS would be Fosfomycin, as it also proves to
have minimal resistance and prevalence of adverse effects. This is a
great second option for this patient, but it has inferior efficacy when
compared to nitrofurantoin.
 The third option for this patient is not a first-line option, but due to the
fact that the patient has already been treated with TMP/SMX in the past
three months, we will be unable to use this as a treatment option.
Therefore, a fluoroquinolone would be an appropriate third option, such
as Ciprofloxacin. This medication has excellent efficacy for
uncomplicated UTIs, but it is known to have a greater chance of adverse
effects.
 Problem 2: Hypertension
o Goal of therapy

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 Reduce associated morbidity and mortality from CV events
Decrease blood pressure to <130/80 mmHg
2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation,
and Management of High Blood Pressure in Adults
o Discussion of subjective and objective information
 The patient is currently taking metoprolol tartrate and her most recent
blood pressure reading was 134/82. As GS has already been diagnosed
with hypertension, her blood pressure would preferably be less than
130/80, which may be elevated due to the infection. If she was not
previously diagnosed with hypertension, her blood pressure should be
less than 120/80. While this may be elevated due to the infection, the
patient is not currently on a first-line treatment for hypertension.
o Treatment Considerations
 Per the 2017 ACC/AHA Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in Adults, the first
line options for patients with hypertension include ACE inhibitors,
ARBs, Calcium channel blockers, and Thiazide diuretics.
 The first option for this patient is a medication in the ACE inhibitors
class, Lisinopril. This is a good option for this patient as it has excellent
efficacy in the treatment of high blood pressure with minimal adverse
effects. This medication is much more efficacious than GS’s current
treatment of metoprolol, which will be discontinued when the patient
starts lisinopril or one of the following options.
 A second option for GS would be Losartan, which is from the ARB class
of hypertension medications. This medication has very similar efficacy
in comparison to Lisinopril, but it is from a different class and works in
a slightly different way. Losartan also has minimal adverse effects
making this a great second option for GS.
 For the third option for GS, a thiazide diuretic, such as
Hydrochlorothiazide would be an acceptable option. This medication
does not tend to have the efficacy that Lisinopril or Losartan has, but it
would still make a good third option. A disadvantage of this medication
is the diuretic effect, which may cause the patient to have more problems
with urinary frequency.
 Problem 3: Anxiety
o Goal of therapy
 Decrease prevalence and severity of symptoms
 Improve quality of life
 2011 NICE Guideline for the Management of Generalised Anxiety
Disorder and Panic Disorder in Adults
o Discussion of subjective and objective information
 The patient stopped her current anxiety medication about 9 months ago
when she started dating her current boyfriend, she has not restarted it
since and has no complaints of symptoms.
o Treatment Considerations

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  Per the 2011 NICE Guidelines for the Management of Generalised
Anxiety Disorder and Panic Disorder in Adults, SSRI’s and SNRI’s are
considered first-line for the treatment of generalized anxiety disorder.
These medications should be trialed for 6 to 8 weeks before determining
treatment failure.
 The patient currently has no complaint of symptoms and therefore a
good first option would be non-pharmacologic therapy, such as
cognitive behavioural therapy. In addition to this, a regular exercise
routine and a healthy diet can properly control anxiety for some patients.
 For a second option, an SNRI such as Venlafaxine XR would be
appropriate. This medication is a different class than her previous
medication (Sertraline, an SSRI) and may not have the adverse effects
that she was experiencing in the past.
 A third option for GS would be Buspirone, a second-line option, this
medication is from a different class and therefore would not have the
sexual dysfunction that is seen in SSRIs and SNRIs. This medication
does not work as well as the other first line options, but it has a different
adverse effect profile which may be beneficial for this patient.

Plan:

 Problem 1: Acute Uncomplicated Cystitis

o Treatment Options:
 Pharm:
 Start Nitrofurantoin 100 mg by mouth twice daily for 5 days
 Safety monitoring:
o Monitor for excessive signs of diarrhea
 Efficacy monitoring:
o Resolution of clinical symptoms
 Counseling:
o This medication can cause brown-colored urine.
o This medication is best taken with food or milk.
o Do not take concurrently with antacids containing
magnesium
 Non pharm:
 Discuss the implications of using spermicidal condoms and suggest
using normal condoms or hormonal contraception
 Talk to patient about the importance of voiding her bladder after
intercourse
 Follow up with PCP in 5 days to ensure patient has experienced a
resolution in clinical symptoms
 Problem 2: Hypertension
o Treatment Options:
 Pharm:
 Start Lisinopril 10 mg by mouth once daily

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  Stop Metoprolol tartrate 50mg
 Safety monitoring:
o Electrolyte levels (Sodium, Potassium), Blood pressure
 Efficacy monitoring:
o Blood pressure monitoring
 Counseling:
o Medication may cause dizziness when it first starts to take
effect, stand up slowly until dizziness has subsided
o This medication may cause a dry hacking cough which may
resolve itself
o Do not suddenly discontinue this medication
 Non pharm:
 Moderate regular exercise (150 minutes per week)
 Follow up with PCP in 1 month to monitor patients blood pressure and
adjust medications as needed
 Problem 3: Anxiety
o Treatment Options:
 Pharm: No current pharmacologic recommendation for this patient
 Non pharm:
 Cognitive behavioural therapy with a trained clinician
 Moderate regular exercise (150 minutes per week)
 Follow up with PCP in 1 month to ensure patient is still doing well
without pharmacologic therapy.
 If patient needs additional assistance, refer to psychiatrist.

Resources: Treatment Guidelines

 2010 IDSA Guidelines for the Treatment of Acute Uncomplicated Cystitis and
Pyelonephritis in Women
 2011 NICE Guideline for the Management of Generalised Anxiety Disorder and Panic
Disorder in Adults
 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management
of High Blood Pressure in Adults,

Writer ID
Emily Seely
Student Pharmacist (Husson University School of Pharmacy)
Phone: 123-456-7890