Prevention measures against urinary tract infections among young women

Soap note response 2

Dear Abby Busch,

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Prevention measures against urinary tract infections among young women
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I support your soap note development for the patient with a chief complaint of vaginal burning and discharge. The personal information acquired through the patient interview is in-depth, providing the detail needed for effective diagnosis (Sherrard et al., 2018). Based on the data obtained, I support your primary diagnosis of Chlamydia which is a sexually transmitted infection. Also, I support your identified differential diagnosis, which has similar symptoms as the primary diagnosis of Chlamydia. Therefore to ensure an accurate diagnosis, the proper test should be done. Your post has identified Endocervical, Amsel Criteria, and urine dipstick tests to support the diagnosis. In addition to this, other tests required to ensure accurate diagnosis for the client are cervical swabs to confirm Chlamydia, wet mount slide under a microscope to look for other infections that can cause the reported symptoms (Sherrard et al., 2018).

As the diagnostic and subjective information is vital to make a diagnosis, no referral is needed, but pharmacological and non-pharmacological intervention is recommended to treat the diagnosis. Additionally, educating the patient on the importance of preventive measures ensures a similar health issue does not arise again in the future. I support your thorough patient assessment and identification of other questions, which helps gather more information vital in making the diagnosis (Yran et al., 2019).  In addition to your post, it is crucial to recommend a female patient schedule an annual well-woman health checkup to ensure productive health even though the shame is associated with seeking sexual care.  I support your reflection on the soap note, which provides evidence-based practice in the development of soap notes to ensure the patient gets the best evidence-based treatment and care. 



Yran, O., Jagodzińska, M., & Nowicki, M. (2019). Knowledge and usage of prevention measures against urinary tract infections among young women. Family Medicine & Primary Care Review, 21(4), 329–334. 

Sherrard, J., Wilson, J., Donders, G., Mendling, W., & Jensen, J. S. (2018). 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. International Journal of STD & AIDS, 29(13), 1258-1272.



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