SOAP Note Patient with UTI
United State College
FNP xxx: Widespread Sickness Throughout the Lifespan -Medical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a feminine affected person offered to the clinic accompany by self, affected person is a dependable historian.
Shopper’s Initials: L.U
Age :65 years.
Race: African American
Gender: Feminine
Date of Start: 08
Insurance coverage: BlueCross BlueShield .
Marital Standing: Married
Subjective: “ I’ve been having ache and burning throughout urination for 2 weeks now and the ache goes to my decrease stomach, and I’ve been unable to carry urine, I now urinate on myself as a result of I can not maintain it till I get to the lavatory”.
CC: Ache and burning throughout urination.
HPI:
Patient acknowledged signs started throughout the previous two weeks and have worsened over the previous seven days. The affected person complains of extreme ache and burning sensation throughout urination that radiates to decrease stomach, with urgency. The urine is cloudy and has a foul odor odor. After trying to move urine, the ache subsides for a short while, but it reoccurs. Patient states that she has been sexually energetic solely with the identical companion for the previous 15 years. On Assessment affected person reviews ache of eight /10 on ache scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest ache for the time being.
ROS
Constitutional: Patient states she is in good state of well being she denies headache , chest ache weak point fever chills, weight reduction or achieve.
Eyes: Denies double imaginative and prescient, change in imaginative and prescient elements, or blurry imaginative and prescient.
Ears/Nostril/Mouth/Throat: denies sore throat, listening to points, or nostril congestion.
Cardiovascular: denies any sort of orthopnea, speedy coronary heart fee, palpitations, or chest ache.
Pulmonary: Denies
Gastrointestinal: c/o average to extreme ache within the belly space.
Genitourinary: acknowledged presence of enhance in urgency and frequency of urination. Main ache whereas urinating for the previous ten days.
Musculoskeletal: Denies any sort of ache
Integumentary & breast: Denies points
Neurological: Denies points
Psychiatric: Denies any sort of melancholy or temper swing
Endocrine: Denies having any downside
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Recognized allergy
Previous Medical Historical past:
● Medical downside listing: affected person denies having any main diseases and solely reviews complications and generally widespread seasonal allergy or chilly.
● Denies historical past of persistent medical issues with father or mom.
● Preventative care: None indicated
● Surgical procedures: Denies
● Hospitalizations: Denies
● LMP: Patient states she do have a 28 days menstrual cycle and the final cycle was 2 weeks in the past. She has had three pregnancies and three cesarean part.
Allergic reactions: No identified meals or drug allergy
● Drugs: Patient takes solely Centrum nutritional vitamins and generally Tylenol for headache. Household Historical past: Patient’s mom has hypertension that she manages by taking each day treatment and exercising. The affected person’s father has hypertension too and takes an analogous remedy strategy as his spouse. Patient has 4 youthful siblings who report not circumstances of bodily circumstances.
● Social Historical past: Patient lives with her companion who’s 5 years older than her. She works with an company as janitor t the place she has been working for the previous ten years. Patient denies any illicit drug use. She stated she has nice help system surrounded with household and associates
Sexual historical past: Patient is sexually energetic has just one companion and they don’t use sort of safety.
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Different:
Very important Indicators: HR:70 BP:122/77 Temp:98.5 RR:18 SpO2:98% Ache:eight/10
Peak: 5ft eight inches Weight: 150lb. BMI: 22.81.
Bodily Examination
Normal Survey: Patient afebrile , no chest ache , no respiration issues or common weak point
A take a look at indicated that affected person had CVA tenderness upon palpitation. There was a suprapubic tenderness on the affected person. A deep belly palpitation on the affected person indicated tenderness.
Assessment
Analysis:
Assessment reveals a scientific end result of dysuria, suprapubic tenderness, and frequency and urgency of urination which signifies UTI (Sabih & Leslie, 2021). Famous no proof of vaginal discharge, so due to this fact not constant with vaginitis
Differential:
1. 2. Pyelonephritis (ICD-9 code 590.80). Ache within the decrease stomach particularly elevated as a result of urination. Pyelonephritis bought eradicated for the reason that affected person didn’t have myalgia, nausea, vomiting, fever, or flank ache (Beahm et al., 2017
2. ). Overactive bladder (ICD 9-596.51). Appropriate since affected person reviews extremely frequent urination. An overactive bladder bought eradicated for the reason that urine dipstick gave a special outcome.
three. Vaginitis (ICD-9-616.10). Ache across the vagina space and decrease stomach. Dominated after dip stick urine.
Analysis:
Assessment reveals a scientific end result of dysuria, suprapubic tenderness, and frequency and urgency of urination which signifies UTI (Sabih & Leslie, 2021). Famous no proof of vaginal discharge, so due to this fact, not constant with vaginitis
Plan
Diagnostics/ Labs : To rule out UTI are urinalysis and urine tradition.
A dipstick urine take a look at reveals presence of nitrite and leukocyte esterase
Remedy:
Double energy prescription of trimethoprim 160 mg and sulfamethoxazole 800 mg 2 occasions each day for 3 days. Patient can even take cranberry juice as research has proven that it is vitally good to deal with UTI due to its acid base properties.
Schooling:
● Instruct affected person to keep away from spermicidal merchandise that enhance threat of a UTI occurring.
● Train affected person to wipe the genital space from entrance to again after urination to keep away from getting micro organism from anus to her virgina
● Train affected person to stick to all remedy instructions
● Train affected person and ensure affected person understands the course of remedy which is 5 days, and to take all treatment identical time every day.
● Train affected person on the significance of ingesting minimal of eight glasses of water per day. Add that this may Help the physique to battle micro organism..
● Train affected person to at all times urinate after sexual activity since that will flush out each bacterium from her urethra
● Train affected person to interact in bodily workout routines since this could enhance her wellbeing and connection to proactive bodily conduct. The affected person ought to take word that each her mother and father have hypertension and will thus get her blood stress studying taken throughout many intervals since this could enable detection of hypertension.
● Train affected person to scale back sexual activity with her companion particularly since she shouldn’t be conscious if she is the one sexual companion her boyfriend has.
● Train affected person to at all times get routine vaccination in opposition to widespread diseases for the reason that method would enable her to have correct wellbeing and administration of her situation. .
● Train affected person to make a timetable of taking water since such fluids would enhance urine and thus, that will flush out micro organism by means of the urethra.
● Train affected person to keep away from sexual activity in the course of the time she is taking treatment to stop any new infections. This can stop affected person from additional getting affected of their potential to obtain full bacterial remedy.
Comply with Up And Suggestions
1. Return to the clinic inside 7 days if signs persist.
2. Pap smear each three years for ages 21- 65.
three. Cranberry Juice can be useful it’s wealthy in vitamin C and potent immune system booster, research point out that it balances the PH of the physique with its acidic properties that helps battle an infection.
References
Beahm, N. P., Nicolle, L. E., Bursey, A., Smyth, D. J., & Tsuyuki, R. T. (2017). The Assessment and administration of urinary tract infections in adults: Pointers for pharmacists. Canadian pharmacists journal : CPJ = Revue des pharmaciens du Canada : RPC, 150(5), 298–305. https://doi.org/10.1177/1715163517723036.
Sabih, A. & Leslie, S.W. (2021). Difficult Urinary Tract Infections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Accessible from: https://www.ncbi.nlm.nih.gov/books/NBK436013/
