Centered SOAP Be aware
Pupil’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Affected person Data:
R.B. 95-year-old, white,
S (subjective)
CC (chief grievance): “My urine is admittedly pink.”
HPI (historical past of current sickness): R.B. 95-year-old, white male, at the moment dwelling in a talented nursing facility (SNF). On Wednesday (2 days in the past) the affected person was dropped at your clinic by his son and complained that his urine seemed to be vivid pink in colour. You ordered labs, urinalysis, tradition, and sensitivity, and the outcomes are beneath.
Present Drugs: Tamsulosin Zero.Four mcg, 2 capsules every day, Aspirin 325 mg every day, Atorvastatin 10 mg 1 pill every 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 as a consequence 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: Embody occupation and main hobbies, household standing, tobacco and alcohol use (earlier and present use), and every other pertinent information. At all times add some well being promo Question Assignment right here, resembling whether or not they use seat belts on a regular basis or whether or not they have working smoke detectors in the home, dwelling atmosphere, textual content/cellular phone use whereas driving, and help system.
Fam Hx: Married and widowed. Youngsters and grandchildren are alive. Lives in a nursing residence.
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 modifications 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 pink.
NEUROLOGICAL: No headache or modifications in bladder management.
MUSCULOSKELETAL: No again ache or muscle stiffness.
HEMATOLOGIC: No bleeding.
LYMPHATICS: Historical past of splenectomy.
PSYCHIATRIC: Historical past of despair or nervousness.
ENDOCRINOLOGIC: No sweating.
REPRODUCTIVE: Not sexually energetic.
ALLERGIES: Penicillin and hives.
O (goal)
Bodily examination:
Very 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
Coloration Pink
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 may cause a change within the colour of the urine. Aged individuals above 50 years have a tumor or modifications in urine colour as a consequence of an enlarged prostate gland (McIntire et al., 2020).
Urinary tract an infection (UTI)
UTI is an an infection of the urinary system inflicting pink colour on the urine. Signs of UTI embrace intense urge to pee, darkish or pink colour of the urine, fever, or chills. Sufferers with UTI require pressing care (Cavanaugh & Perazella, 2019).
Kidney cysts
Kidney cysts might trigger no antagonistic signs however sufferers can expertise pink 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 needs to 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 remedy and report back to the clinic after two weeks.
I discovered that aged males are vulnerable to the enlarged prostate gland which will increase the danger of pink and darkish urine. It’s important to diagnose the affected person to make sure acceptable remedy.
The affected person ought to drink ample water every day and keep away from laborious duties which will trigger sweating. It is very important eat a nutritious diet to spice up immunity. The practitioner ought to preserve confidentiality within the supply of care.
References
Alaygut, D., Erfidan, G., Soyaltın, E., Siviş, Z. Ö., Çamlar, S. A., Mutlubaş, F., & Demir, B. Ok. (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.
