| Course | NUR 656 Primary Care of Women |
|---|---|
| Module | Module 4 |
| Paper type | SOAP note for acute uncomplicated cystitis |
| Length | About 1,010 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 656 Module 4
SOAP Note: Acute Uncomplicated Cystitis in a 24-Year-Old Woman
[Student Name]
Southern New Hampshire University
NUR 656: Primary Care of Women
Module Four SOAP Note
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
SOAP Note: Acute Uncomplicated Cystitis in a 24-Year-Old Woman
Acute cystitis is among the most common reasons women seek care, and most episodes can be diagnosed from symptoms and treated with a short course of antibiotics. Doing it well still requires judgment: confirming that the infection is uncomplicated, considering conditions that mimic it, choosing an antibiotic that preserves effective drugs for serious infections and recognizing when a young woman's symptoms may reflect a sexually transmitted infection. This SOAP note documents the care of a 24-year-old with classic symptoms. It argues that symptom-based diagnosis, a guideline-based first-line antibiotic and attention to sexual health provide efficient, safe care.
Subjective
Chief concern: "It burns when I pee and I keep having to go."
History of present illness: Jasmine is a 24-year-old with two days of burning on urination, urinating every hour and a constant urge to go. She noticed pink-tinged urine this morning. Asked directly, she reports no discharge, itch or odor, and no fever, shaking, back or side pain, nausea or vomiting. She has had one similar episode two years ago that resolved with antibiotics. Her last menstrual period ended ten days ago. She has one male partner of eight months and uses a combined vaginal ring for contraception; condoms are used occasionally. Her last antibiotic course was more than a year ago, and she has no known urinary tract abnormalities, diabetes or kidney disease. Allergies: none. Medications: contraceptive ring.
Objective
Temperature 36.9 degrees Celsius, blood pressure 112/70, heart rate 78. She appears comfortable. Mild suprapubic tenderness without costovertebral angle tenderness. No pelvic examination was performed because she reports no vaginal symptoms. Her urine hCG is negative. On dipstick the pad for leukocytes and the pad for nitrite are both positive, with a moderate blood reading.
Assessment
1. Acute uncomplicated cystitis. Bent et al. (2002) reviewed the accuracy of history and examination for urinary tract infection in women and found that when burning and frequent urination occur together and the woman has no discharge or vaginal irritation, the probability of infection exceeds 90%, high enough that further testing adds little. Her infection is uncomplicated because she is not pregnant, is premenopausal, has no known structural or functional urinary abnormality or immune compromise and has no fever, flank pain or systemic symptoms suggesting kidney involvement. A urine culture is not required for a first uncomplicated episode that responds to treatment.
Differential diagnoses: pyelonephritis, unlikely without fever or flank tenderness; urethritis from chlamydia or gonorrhea, which can cause dysuria and pyuria and is more common in women under 25; and vaginitis, unlikely without discharge or itching.
Choosing the Antibiotic
The IDSA guideline for acute uncomplicated cystitis recommends nitrofurantoin monohydrate macrocrystals 100 mg twice daily for five days as a first-line option; trimethoprim-sulfamethoxazole for three days is appropriate where local resistance rates are below 20% and the patient has not used it recently; and single-dose fosfomycin is an option with somewhat lower efficacy. It advises reserving fluoroquinolones for other uses because of resistance and adverse effects (Gupta et al., 2011). The regional antibiogram shows about 24% resistance to trimethoprim-sulfamethoxazole among community E. coli isolates, which argues against it.
Huttner et al. (2018) compared five days of nitrofurantoin with a single dose of fosfomycin in a randomized trial of women with uncomplicated lower urinary tract infection in several countries. Clinical resolution at 28 days occurred in 70% of women receiving nitrofurantoin and 58% of those receiving fosfomycin. Nitrofurantoin was therefore chosen.
Stewardship and When a Culture Is Needed
Every antibiotic course for a simple infection shapes the resistance patterns that determine whether serious infections can be treated. That is why fluoroquinolones, which remain important for pyelonephritis and other complicated infections, are not used for simple cystitis, and why local resistance data guide the choice among first-line agents. Nitrofurantoin concentrates in the bladder, has little effect on bowel flora and has retained activity against most community E. coli isolates, which makes it a good stewardship choice. It should not be used when kidney infection is suspected, since it does not reach effective levels in kidney tissue, or in women with significantly reduced kidney function.
A urine culture is not needed for Jasmine's first uncomplicated episode, but it becomes important in several situations: symptoms that persist after 48 to 72 hours of treatment or recur within a month, suspected pyelonephritis, pregnancy, recent antibiotic exposure or a history of resistant organisms. In those cases, culture results guide a change in therapy and help detect resistance early.
If Jasmine develops recurrent infections, defined as two or more in six months or three or more in a year, the next steps would include a culture with each episode, a review of contributing factors such as spermicide use and a discussion of prevention strategies, including postcoital or continuous low-dose prophylaxis and patient-initiated treatment with a standing prescription.
Plan
Nitrofurantoin (macrocrystal form) 100 mg orally every twelve hours, taken with meals, for five days. Phenazopyridine 200 mg three times daily for up to two days for discomfort, with a warning that it turns urine orange. An amplified DNA test of the same urine sample for chlamydia and gonorrhea, since screening is recommended for sexually active women under 25; she will be contacted if results are positive. She was told her vaginal ring can be continued, since nitrofurantoin does not reduce its effectiveness.
She should call back for fever, shaking chills, back or side pain or vomiting, or if symptoms are not easing after 48 hours of treatment or that return within two weeks, in which case a urine culture will be obtained. Prevention advice included adequate fluids and urinating soon after intercourse, while noting that evidence for these measures is limited. Condom use was encouraged for STI prevention.
Conclusion
Jasmine's symptoms made cystitis very likely, and her history confirmed it was uncomplicated. A five-day course of nitrofurantoin, chosen according to guideline, local resistance and trial evidence, should resolve the infection, and chlamydia and gonorrhea testing addresses the possibility that her symptoms have a sexually transmitted cause. Clear return precautions ensure that the rare complication is caught early.
References
Bent, S., Nallamothu, B. K., Simel, D. L., Fihn, S. D., & Saint, S. (2002). Does this woman have an acute uncomplicated urinary tract infection? JAMA, 287(20), 2701-2710. https://doi.org/10.1001/jama.287.20.2701
Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103-e120. https://doi.org/10.1093/cid/ciq257
Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., Kosiek, K., Martinez de Tejada, B., Roux, X., Shiber, S., Theuretzbacher, U., von Dach, E., Yahav, D., Leibovici, L., Godycki-Cwirko, M., Mouton, J. W., & Harbarth, S. (2018). Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women: A randomized clinical trial. JAMA, 319(17), 1781-1789. https://doi.org/10.1001/jama.2018.3627
What the NUR 656 Module 4 instructions ask for
SOAP notes on urinary complaints in NUR 656 usually ask for a focused history, examination and testing, an assessment that classifies the infection and considers mimics and a plan with antibiotic choice, education and follow-up. Expect three to four pages in APA 7 in your program's template. Document the symptoms and their absence, such as no discharge, fever or flank pain, record pregnancy status, state explicitly why the infection is uncomplicated or complicated, justify the antibiotic with the guideline and local resistance data, check for drug interactions with contraception and address sexual health for young women, with clear return precautions. State when a culture would be needed and how recurrence would be handled.
How this NUR 656 Module 4 soap note example is built
This note documents a composite 24-year-old with two days of dysuria, frequency and urgency and no discharge, fever or flank pain. The Bent review shows that this combination raises the probability of infection above 90%. The assessment lists the criteria for uncomplicated cystitis and considers pyelonephritis, urethritis and vaginitis. The Gupta IDSA guideline and a 24% local resistance rate lead away from trimethoprim-sulfamethoxazole, and the Huttner trial, with 70% versus 58% resolution, supports nitrofurantoin for five days. The plan adds chlamydia and gonorrhea testing, confirms the ring remains effective and gives return precautions. A stewardship section explains why fluoroquinolones are avoided and lists when a culture is required.
Where the NUR 656 Module 4 rubric puts the points
Grading of urinary infection notes commonly weighs the completeness of the history, appropriate testing, correct classification of the infection, differential diagnosis, evidence-based antibiotic selection, education and APA 7 writing. Top-band notes state why the infection meets criteria for uncomplicated cystitis and justify the antibiotic using guideline recommendations and local resistance. Graders reward attention to sexually transmitted infections in young women, checks for interactions with contraception and return precautions that specify when to seek care and when a culture is needed. Avoiding fluoroquinolones for simple cystitis reflects the stewardship reviewers expect. Clear criteria for culture and recurrence evaluation strengthen the plan and show stewardship. Checking contraceptive interactions is also valued.
NUR 656 Module 4 help: the mistakes that cost points
Cystitis notes lose points when pregnancy status is missing, when the infection is not classified, when fluoroquinolones are prescribed for simple cystitis, when local resistance is ignored or when STI testing is omitted for young sexually active women. Another gap is vague return precautions. Document key positives and negatives, classify the infection, choose an antibiotic by guideline and resistance, test for STIs when indicated, check contraceptive interactions and give specific precautions. If your case involves recurrent infections, pregnancy or an older woman, send it with your NUR 656 template so the note follows the right guidance. Name the triggers for a culture and define recurrence. Confirm her contraception still works.
Get NUR 656 Module 4 written to your instructions
Send us the NUR 656 case, your SOAP template and how the note is graded. We will classify the infection explicitly, justify the antibiotic with guideline and resistance data, address sexual health and give specific return precautions, within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 656 Module 4 questions, answered
Where can I find a free NUR 656 Module 4 SOAP Note sample?
This page carries the full note: uncomplicated cystitis in a 24-year-old, symptom-based diagnosis, nitrofurantoin by IDSA guidance and STI testing.
What makes cystitis uncomplicated?
Occurring in a nonpregnant, premenopausal woman with no urinary abnormalities, immune compromise or signs of kidney infection such as fever or flank pain.
What is first-line treatment for uncomplicated cystitis?
The IDSA guideline lists nitrofurantoin 100 mg twice daily for five days, with trimethoprim-sulfamethoxazole for three days if local resistance is below 20%.
Is nitrofurantoin better than single-dose fosfomycin?
In a randomized trial, clinical resolution at 28 days was 70% with five days of nitrofurantoin versus 58% with single-dose fosfomycin.
Why test for chlamydia in a young woman with dysuria?
Chlamydia and gonorrhea can cause urethritis with dysuria and pyuria, and screening is recommended for sexually active women under 25.