Operating head: SOAP NOTE 1
SOAP NOTE four
Title: R.T
Date: 03-16-2020
Age: 29
Intercourse: F
SUBJECTIVE
CC:
“I’m urinating on a regular basis, and it burns after I urinate”
HPI:
It is a 29-year-old African American girl presenting immediately to the clinic with persevering with complaints of dysuria, urgency to urinate, and frequency of urination. She states that she has just lately observed that her urine has a “foul and unsightly odor”. The affected person additionally complains of a gentle fever. She contends that bodily and emotional stress typically exacerbate the signs.
Medicines
None
PMH
Allergy symptoms: Affected person experiences no meals, environmental, or drug allergy symptoms
Remedy Intolerances: N/A
Persistent Sicknesses/Main traumas: No power diseases or main traumas
Hospitalizations/Surgical procedures: None
Household Historical past
Affected person’s father presently alive at age 61, identified with cardiac illness.
Mom handed away three years in the past from a tragic highway accident.
Affected person has two older sibling, each of whom are alive and effectively.
Social Historical past
EM works as a gross sales consultant for a clothier retailer within the state. She denies cigarette smoking however admits to social ETOH use and occasional marijuana use. She states that for the previous 7 months, she has been sexually lively with one male associate. Affected person additionally asserts that for contraception, she makes use of spermicide-coated condoms
ROS
Normal
Endorses gentle fevers however denies chills, malaise, night time sweats, fatigue, or latest weight adjustments
Cardiovascular
Affected person denies palpitations, claudication, chest ache, or orthopnea
Pores and skin
EM denies adjustments in moles, rashes, itching, straightforward bruising, or bites
Respiratory
Denies painful respiration, SOB, irregular sputum manufacturing or cough. She doesn’t recall even taking a TB pores and skin check
Eyes
Denies visible loss, double imaginative and prescient, or blurred imaginative and prescient. She states she has no historical past of cataracts or glaucoma.
Gastrointestinal
Affected person denies belly ache, issue swallowing, vomiting, intolerance to meals, urge for food adjustments, or stool adjustments
Ears
Denies ear ache, ear infections, or tinnitus
Genitourinary/Gynecological
Affected person does report urgency, frequency, dysuria, odorous urine and suprapubic ache. She experiences voiding no less than 15 instances each day. She nonetheless rebuts flank ache, hematuria and historical past of STIs. LMP 1 week in the past, no heavy bleeding. She confides that she makes use of spermicide-coated condoms for contraception.
Nostril/Mouth/Throat
EM denies nasal ache, congestion or different sinus issues. Refutes throat swelling or ache
Musculoskeletal
Denies limits to ROM, swelling, muscle ache, or heat joints
Breast
She denies discharge, redness, tenderness or every other breast adjustments
Neurological
Affected person rebuts coordination difficulties, paralysis, tremors, seizures, or syncope
Heme/Lymph/Endo
Foregone
Psychiatric
Denies issues with focus, nervousness, emotions of irritability, temper adjustments, or depressive signs
OBJECTIVE
Weight: 143lbs BMI: 23.1
Temp: 37.3oC
BP: 124/82
Peak: 5’6’’
Pulse: 74
Resp: 16
Normal Look
Cooperative Caucasian girl showing her age, she appears in no misery
Pores and skin
No pores and skin lesions noticed upon bodily examination
HEENT
Head normocephalic with regular hair distribution. No facial swelling famous. Eyes: PERRLA; EOMI. Fundi benign. Ears: TMs intact with no erythema. Nostril: Mucous membranes moist. Nasopharynx with out erythema, exudates, or lesions. Mouth: Good dentition, no lacking tooth
Cardiovascular
S1 & S2 regular with out MRG. No carotid bruits. (-) JVD
Respiratory
Lungs CTA posteriorly and anteriorly
Gastrointestinal
Stomach delicate and nontender. (+) bowel sounds
Breast
No nipple retraction, lymphadenopathy, or nipple discharge
Genitourinary
Gentle suprapubic tenderness famous with palpation. No inguinal hernias or CVA tenderness. Vaginal mucosa pink, no discharge, minimal rugae. Bimanual examination reveals no lots. Affected person reported tenderness over the bladder base after making use of stress to the anterior vaginal wall in the course of the bimanual examination. Perineum intact with out lesion. Rectovaginal examination – sphincter tone intact, septum intact; no tenderness or lots
Musculoskeletal
ROM WNL with out crepitus or ache
Neurological
Cranial nerves II-XII intact. (-) Romberg examination. Motor and sensory ranges intact
Psychiatric
Affected person alert and oriented × three. She seems to have regular have an effect on and is ready to observe instructions
Lab Checks
Urinalysis – Yellow, cloudy; WBC 10–15 cells/hpf; RBC 1–5 cells/hpf; pH 5.Zero; protein 10 mg/dL; glucose (–); leukocyte esterase (+); hint blood; nitrite optimistic; many micro organism
Pelvic ultrasound – Unfavourable for uterine fibroids and ovarian cysts
Urine tradition—pending
Particular Checks: None
Analysis
Analysis:
· N30.90-Cystitis, unspecified with out hematuria (dysuria, urgency to urinate, and frequency of urination are all widespread indicators of cystitis. Tenderness over the bladder base after making use of stress to the anterior vaginal wall in the course of the bimanual examination, gentle suprapubic tenderness, and urinalysis findings additionally help cystitis because the definitive prognosis)
Differential Analysis:
· N39.Zero- Urinary Tract An infection: Urinary tract infections do not at all times trigger indicators and signs, however after they do they could embody a robust, persistent urge to urinate, burning sensation when urinating, passing frequent, small quantities of urine, urine that seems cloudy, crimson, shiny pink or cola-colored (an indication of blood within the urine), strong-smelling urine, pelvic ache, in girls (particularly within the middle of the pelvis and across the space of the pubic bone)
· N10– Acute Pyelonephritis: Traditional presentation in acute pyelonephritis is the triad of fever, costovertebral angle ache, and nausea and/or vomiting. These could not all be current, nonetheless, or they could not happen collectively temporally. Signs could also be minimal to extreme and normally develop over hours or over the course of a day. Sometimes, signs develop over a number of days and will even be current for a number of weeks earlier than the affected person seeks medical care. Signs of cystitis could or might not be current to various levels. These could embody urinary frequency, hesitancy, decrease belly ache, and urgency.
· N76.Zero– Vaginitis: Vaginitis is an irritation of the vagina that can lead to discharge, itching and ache. The trigger is normally a change within the regular stability of vaginal micro organism or an an infection. Diminished estrogen ranges after menopause and a few pores and skin issues can even trigger vaginitis.
PLAN
· Additional testing; Urine Tradition
· Remedy: nitrofurantoin 100 mg twice per day for five days.
· Schooling: Affected person schooling was basic in the course of the encounter with this affected person. The affected person obtained counseling about sure meals and substances which will set off cystitis symptom flares together with espresso and caffeinated drinks, soda, alcoholic drinks, citrus fruits and juices, spicy meals equivalent to scorching peppers, synthetic sweeteners in addition to meals components and preservatives. Affected person additionally obtained details about self-care methods that would assist her in managing the signs of acute uncomplicated cystitis. A few of these methods included managed fluid consumption, ache reduction methods (e.g. heat sitz tub), mild train, and bodily remedy
· Observe-up: scheduled after 1 week. Nonetheless, clinician suggested the affected person to return if the signs progress regardless of remedy or in the event that they fail to resolve inside 72 hours
References
Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Prepare dinner, J. (2015). Major Care: A Collaborative
Observe. Elsevier Well being Sciences
Codina, M. L. (2018). Household Nurse Practitioner Certification: Quick Information and Lively Questions. Third
Version. New York: Springer Publishing Firm
Blunt, E. (2009). Household Nurse Practitioner: Nursing Evaluate and Useful resource guide ( 4th ed., Vol 1).Silver
Spring, MD: American Nurses Credentialing Middle.
www.epocrates.com
Bethel, J. (2012). Acute pyelonephritis: threat components, prognosis and remedy. Nursing Normal, 27(5), 51–
56. Retrieved from
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