Targeted SOAP Word
Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Affected person Info:
R.B. 95-year-old, white,
S (subjective)
CC (chief grievance): “My urine is actually crimson.”
HPI (historical past of current sickness): R.B. 95-year-old, white male, at present residing in a talented nursing facility (SNF). On Wednesday (2 days in the past) the affected person was delivered to your clinic by his son and complained that his urine gave the impression to be brilliant crimson in coloration. You ordered labs, urinalysis, tradition, and sensitivity, and the outcomes are under.
Present Drugs: Tamsulosin Zero.Four mcg, 2 capsules each day, Aspirin 325 mg each day, Atorvastatin 10 mg 1 pill each day, Donepezil 10 mg 1 pill PO QHS, Metoprolol 25 mg Zero.5 mg pill each 12 hours, Acetaminophen 500 mg 1 pill BID.
Allergic reactions: Penincilin and hives
PMHx: Cognitive communication deficit, pneumonitis because of inhalation of meals and vomit, dysphagia, R-side hemiplegia and hemiparesis previous ischemic CVA, average vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left decrease extremity, gross hematuria.
Soc and Substance Hx: Embrace occupation and main hobbies, household standing, tobacco and alcohol use (earlier and present use), and another pertinent information. All the time add some well being promo Question Assignment right here, reminiscent of whether or not they use seat belts on a regular basis or whether or not they have working smoke detectors in the home, residing atmosphere, textual content/mobile phone use whereas driving, and help system.
Fam Hx: Married and widowed. Kids and grandchildren are alive. Lives in a nursing dwelling.
Surgical Hx: Splenectomy at 55 years.
Psychological Hx: Historical past of despair and suicidal ideation. Handled with no reoccurrence.
Violence Hx: No historical past of violence self-harm.
Reproductive Hx: Not sexually energetic. Has three daughters.
ROS (evaluate of signs):
GENERAL: No unintentional weight adjustments or fever.
HEENT:
• Eyes: No visible loss or watery eyes.
• Ears, Nostril, Throat: No listening to loss, congestion of the nostril, or sore throat.
SKIN: No rashes.
CARDIOVASCULAR: No palpitation or edema.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: No nausea or vomiting.
GENITOURINARY: Urine is crimson.
NEUROLOGICAL: No headache or adjustments in bladder management.
MUSCULOSKELETAL: No again ache or muscle stiffness.
HEMATOLOGIC: No bleeding.
LYMPHATICS: Historical past of splenectomy.
PSYCHIATRIC: Historical past of despair or anxiousness.
ENDOCRINOLOGIC: No sweating.
REPRODUCTIVE: Not sexually energetic.
ALLERGIES: Penicillin and hives.
O (goal)
Bodily examination:
Important indicators: BP 122/70, HR 66, Temp 98.Zero F, Resp 18, Pulse ox 98.
Diagnostic outcomes:
Labs:
RBC three.53 (L)
Hemoglobin 10.2 (L)
Microscopic Assessment, Urine, straight Cath
Part:
WBC UA 42 (H) (Zero-5/ HPF)
RBC, UA >900 (H) (Zero-5/HPF)
Epithelial cells, urine 2 (Zero-Four /HPF)
Hyaline casts, UA Zero (Zero-2 /LPF)
Urinalysis
Shade Crimson
Look (Urine): Clear
Ketones, UA Hint
Particular gravity 1.020 (1.005-1.Zero25)
Blood, UA Massive
PH, Urine 7.Zero (5.Zero-Eight.Zero)
Leukocytes Small
Nitrites Constructive
A (Assessment)
Differential diagnoses:
Cancerous and noncancerous tumors
A tumor within the urinary system could cause a change within the coloration of the urine. Aged individuals above 50 years have a tumor or adjustments in urine coloration because of an enlarged prostate gland (McIntire et al., 2020).
Urinary tract an infection (UTI)
UTI is an an infection of the urinary system inflicting crimson coloration on the urine. Signs of UTI embrace intense urge to pee, darkish or crimson coloration of the urine, fever, or chills. Sufferers with UTI require pressing care (Cavanaugh & Perazella, 2019).
Kidney cysts
Kidney cysts could trigger no antagonistic signs however sufferers can expertise crimson urine if the cysts burst. Sufferers with kidney cysts are prone to expertise intense and frequent urges to urinate (Alaygut et al., 2021).
P (plan)
The affected person must be referred for an X-ray and extra examination of the urine to find out the suitable analysis. The affected person ought to begin taking treatment and report back to the clinic after two weeks.
I realized that aged males are liable to the enlarged prostate gland which will increase the chance of crimson and darkish urine. It’s important to diagnose the affected person to make sure applicable therapy.
The affected person ought to drink enough water each day and keep away from arduous duties that will trigger sweating. It is very important eat a nutritious diet to spice up immunity. The practitioner ought to keep confidentiality within the supply of care.
References
Alaygut, D., Erfidan, G., Soyaltın, E., Siviş, Z. Ö., Çamlar, S. A., Mutlubaş, F., & Demir, B. Okay. (2021). What does acute kidney damage and darkish red-brown urine that seem after bone marrow transplantation inform us: Questions. Pediatric Nephrology, 36(1), 65-66.
Cavanaugh, C., & Perazella, M. A. (2019). Urine sediment examination within the analysis and administration of kidney illness: core curriculum 2019. American Journal of Kidney Ailments, 73(2), 258-272.
McIntire, P. J., Kilic, I., Wojcik, E. M., Barkan, G. A., & Pambuccian, S. E. (2020). The colour of urine: then and now—a complete evaluate of the literature with emphasis on intracytoplasmic pigments encountered in urinary cytology. Journal of the American Society of Cytopathology, 9(1), 9-19.
