Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Patient Information:
R.B. 95-year-old, white,
S (subjective)
CC (chief complaint): “My urine is really red.”
HPI (history of present illness): R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF). On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.
Current Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID.
Allergies: Penincilin and hives
PMHx: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Married and widowed. Children and grandchildren are alive. Lives in a nursing home.
Surgical Hx: Splenectomy at 55 years.
Mental Hx: History of depression and suicidal ideation. Treated with no reoccurrence.
Violence Hx: No history of violence self-harm.
Reproductive Hx: Not sexually active. Has three daughters.
ROS (review of symptoms):
GENERAL: No unintentional weight changes or fever.
HEENT:
• Eyes: No visual loss or watery eyes.
• Ears, Nose, Throat: No hearing loss, congestion of the nose, or sore throat.
SKIN: No rashes.
CARDIOVASCULAR: No palpitation or edema.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: No nausea or vomiting.
GENITOURINARY: Urine is red.
NEUROLOGICAL: No headache or changes in bladder control.
MUSCULOSKELETAL: No back pain or muscle stiffness.
HEMATOLOGIC: No bleeding.
LYMPHATICS: History of splenectomy.
PSYCHIATRIC: History of depression or anxiety.
ENDOCRINOLOGIC: No sweating.
REPRODUCTIVE: Not sexually active.
ALLERGIES: Penicillin and hives.
O (objective)
Physical exam:
Vital signs: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98.
Diagnostic results:
Labs:
RBC 3.53 (L)
Hemoglobin 10.2 (L)
Microscopic Analysis, Urine, straight Cath
Component:
WBC UA 42 (H) (0-5/ HPF)
RBC, UA >900 (H) (0-5/HPF)
Epithelial cells, urine 2 (0-4 /HPF)
Hyaline casts, UA 0 (0-2 /LPF)
Urinalysis
Color Red
Appearance (Urine): Clear
Ketones, UA Trace
Specific gravity 1.020 (1.005-1.025)
Blood, UA Large
PH, Urine 7.0 (5.0-8.0)
Leukocytes Small
Nitrites Positive
A (assessment)
Differential diagnoses:
Cancerous and noncancerous tumors
A tumor in the urinary system can cause a change in the color of the urine. Elderly people above 50 years have a tumor or changes in urine color due to an enlarged prostate gland (McIntire et al., 2020).
Urinary tract infection (UTI)
UTI is an infection of the urinary system causing red color on the urine. Symptoms of UTI include intense urge to pee, dark or red color of the urine, fever, or chills. Patients with UTI require urgent care (Cavanaugh & Perazella, 2019).
Kidney cysts
Kidney cysts may cause no adverse symptoms but patients can experience red urine if the cysts burst. Patients with kidney cysts are likely to experience intense and frequent urges to urinate (Alaygut et al., 2021).
P (plan)
The patient should be referred for an X-ray and additional examination of the urine to determine the appropriate diagnosis. The patient should start taking medication and report to the clinic after two weeks.
I learned that elderly men are at risk of the enlarged prostate gland which increases the risk of red and dark urine. It is essential to diagnose the patient to ensure appropriate treatment.
The patient should drink sufficient water daily and avoid hard tasks that may cause sweating. It is important to eat a healthy diet to boost immunity. The practitioner should maintain confidentiality in the delivery of care.
References
Alaygut, D., Erfidan, G., Soyaltın, E., Siviş, Z. Ö., Çamlar, S. A., Mutlubaş, F., & Demir, B. K. (2021). What does acute kidney injury and dark red-brown urine that appear after bone marrow transplantation tell us: Questions. Pediatric Nephrology, 36(1), 65-66.
Cavanaugh, C., & Perazella, M. A. (2019). Urine sediment examination in the diagnosis and management of kidney disease: core curriculum 2019. American Journal of Kidney Diseases, 73(2), 258-272.
McIntire, P. J., Kilic, I., Wojcik, E. M., Barkan, G. A., & Pambuccian, S. E. (2020). The color of urine: then and now—a comprehensive review of the literature with emphasis on intracytoplasmic pigments encountered in urinary cytology. Journal of the American Society of Cytopathology, 9(1), 9-19.
