Working head: SOAP NOTE 1
SOAP NOTE 4
Title: R.T
Date: 03-16-2020
Age: 29
Intercourse: F
SUBJECTIVE
CC:
“I am urinating frequently, and it burns after I urinate”
HPI:
It’s a 29-year-old African American woman presenting instantly to the clinic with persevering with complaints of dysuria, urgency to urinate, and frequency of urination. She states that she has simply currently noticed that her urine has a “foul and ugly odor”. The affected particular person moreover complains of a delicate fever. She contends that bodily and emotional stress usually exacerbate the indicators.
Medicines
None
PMH
Allergy signs: Affected particular person experiences no meals, environmental, or drug allergy signs
Treatment Intolerances: N/A
Persistent Sicknesses/Predominant traumas: No energy ailments or important traumas
Hospitalizations/Surgical procedures: None
Family Historic previous
Affected particular person’s father presently alive at age 61, recognized with cardiac sickness.
Mother handed away three years up to now from a tragic freeway accident.
Affected particular person has two older sibling, every of whom are alive and successfully.
Social Historic previous
EM works as a product sales marketing consultant for a clothier retailer inside the state. She denies cigarette smoking nevertheless admits to social ETOH use and occasional marijuana use. She states that for the earlier 7 months, she has been sexually full of life with one male affiliate. Affected particular person moreover asserts that for contraception, she makes use of spermicide-coated condoms
ROS
Regular
Endorses light fevers nevertheless denies chills, malaise, night time time sweats, fatigue, or newest weight changes
Cardiovascular
Affected particular person denies palpitations, claudication, chest ache, or orthopnea
Pores and pores and skin
EM denies changes in moles, rashes, itching, easy bruising, or bites
Respiratory
Denies painful respiration, SOB, irregular sputum manufacturing or cough. She does not recall even taking a TB pores and pores and skin examine
Eyes
Denies seen loss, double imaginative and prescient, or blurred imaginative and prescient. She states she has no historic previous of cataracts or glaucoma.
Gastrointestinal
Affected particular person denies stomach ache, problem swallowing, vomiting, intolerance to meals, urge for meals changes, or stool changes
Ears
Denies ear ache, ear infections, or tinnitus
Genitourinary/Gynecological
Affected particular person does report urgency, frequency, dysuria, odorous urine and suprapubic ache. She experiences voiding a minimum of 15 situations every day. She nonetheless rebuts flank ache, hematuria and historic previous of STIs. LMP 1 week up to now, no heavy bleeding. She confides that she makes use of spermicide-coated condoms for contraception.
Nostril/Mouth/Throat
EM denies nasal ache, congestion or completely different sinus points. Refutes throat swelling or ache
Musculoskeletal
Denies limits to ROM, swelling, muscle ache, or warmth joints
Breast
She denies discharge, redness, tenderness or each different breast changes
Neurological
Affected particular person rebuts coordination difficulties, paralysis, tremors, seizures, or syncope
Heme/Lymph/Endo
Foregone
Psychiatric
Denies points with focus, nervousness, feelings of irritability, mood changes, or depressive indicators
OBJECTIVE
Weight: 143lbs BMI: 23.1
Temp: 37.3oC
BP: 124/82
Peak: 5’6’’
Pulse: 74
Resp: 16
Regular Look
Cooperative Caucasian woman exhibiting her age, she seems in no distress
Pores and pores and skin
No pores and pores and skin lesions seen upon bodily examination
HEENT
Head normocephalic with common hair distribution. No facial swelling well-known. 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 missing tooth
Cardiovascular
S1 & S2 common with out MRG. No carotid bruits. (-) JVD
Respiratory
Lungs CTA posteriorly and anteriorly
Gastrointestinal
Abdomen delicate and nontender. (+) bowel sounds
Breast
No nipple retraction, lymphadenopathy, or nipple discharge
Genitourinary
Mild suprapubic tenderness well-known with palpation. No inguinal hernias or CVA tenderness. Vaginal mucosa pink, no discharge, minimal rugae. Bimanual examination reveals no heaps. Affected particular person reported tenderness over the bladder base after making use of stress to the anterior vaginal wall in the middle of the bimanual examination. Perineum intact with out lesion. Rectovaginal examination – sphincter tone intact, septum intact; no tenderness or heaps
Musculoskeletal
ROM WNL with out crepitus or ache
Neurological
Cranial nerves II-XII intact. (-) Romberg examination. Motor and sensory ranges intact
Psychiatric
Affected particular person alert and oriented × three. She appears to have common impact and is able to observe directions
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 (+); trace blood; nitrite optimistic; many micro organism
Pelvic ultrasound – Unfavourable for uterine fibroids and ovarian cysts
Urine custom—pending
Explicit Checks: None
Assessment
Assessment:
· 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 middle of the bimanual examination, light suprapubic tenderness, and urinalysis findings moreover Help cystitis as a result of the definitive prognosis)
Differential Assessment:
· N39.Zero- Urinary Tract An an infection: Urinary tract infections don’t always set off indicators and indicators, nevertheless after they do they may embody a sturdy, persistent urge to urinate, burning sensation when urinating, passing frequent, small portions of urine, urine that appears cloudy, crimson, shiny pink or cola-colored (a sign of blood inside the urine), strong-smelling urine, pelvic ache, in ladies (significantly inside the center of the pelvis and throughout the area of the pubic bone)
· N10– Acute Pyelonephritis: Conventional presentation in acute pyelonephritis is the triad of fever, costovertebral angle ache, and nausea and/or vomiting. These couldn’t all be present, nonetheless, or they may not occur collectively temporally. Indicators is also minimal to excessive and usually develop over hours or over the course of a day. Generally, indicators develop over a lot of days and can even be present for a lot of weeks sooner than the affected particular person seeks medical care. Indicators of cystitis may or may not be present to numerous ranges. These may embody urinary frequency, hesitancy, lower stomach ache, and urgency.
· N76.Zero– Vaginitis: Vaginitis is an irritation of the vagina that may result in discharge, itching and ache. The set off is often a change inside the common stability of vaginal micro organism or an an an infection. Diminished estrogen ranges after menopause and some pores and pores and skin points may even set off vaginitis.
PLAN
· Further testing; Urine Custom
· Treatment: nitrofurantoin 100 mg twice per day for 5 days.
· Education: Affected particular person education was fundamental in the middle of the encounter with this affected particular person. The affected particular person obtained counseling about positive meals and substances which can set off cystitis symptom flares along with espresso and caffeinated drinks, soda, alcoholic drinks, citrus fruits and juices, spicy meals equal to scorching peppers, artificial sweeteners along with meals parts and preservatives. Affected particular person moreover obtained particulars about self-care strategies that might help her in managing the indicators of acute uncomplicated cystitis. Just a few of those strategies included managed fluid consumption, ache discount strategies (e.g. warmth sitz tub), gentle prepare, and bodily treatment
· Observe-up: scheduled after 1 week. Nonetheless, clinician recommended the affected particular person to return if the indicators progress no matter treatment or within the occasion that they fail to resolve inside 72 hours
References
Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Put together dinner, J. (2015). Main Care: A Collaborative
Observe. Elsevier Effectively being Sciences
Codina, M. L. (2018). Family Nurse Practitioner Certification: Fast Data and Energetic Questions. Third
Model. New York: Springer Publishing Agency
Blunt, E. (2009). Family Nurse Practitioner: Nursing Consider and Helpful useful resource information ( 4th ed., Vol 1).Silver
Spring, MD: American Nurses Credentialing Center.
www.epocrates.com
Bethel, J. (2012). Acute pyelonephritis: menace parts, prognosis and treatment. Nursing Regular, 27(5), 51–
56. Retrieved from
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