Soap note # 1 , Diabetic Patient, please see attached form. Name: R.T Date: 03-16-2020Age: 29Sex: FSUBJECTIVECC: “I am urinating all the time, and it burns when I urinate”HPI: This is a 29-year-old African American woman presenting today to the clinic with continuing complaints of dysuria, urgency to urinate, and frequency of urination. She states that she has recently noticed that her urine has a “foul and unpleasant smell”.
The patient also complains of a mild fever. She contends that physical and emotional stress often exacerbate the symptoms. MedicationsNone PMHAllergies: Patient reports no food, environmental, or drug allergiesMedication Intolerances: N/AChronic Illnesses/Major traumas: No chronic illnesses or major traumasHospitalizations/Surgeries: None Family HistoryPatient’s father currently alive at age 61, diagnosed with cardiac disease.Mother passed away three years ago from a tragic road accident.
Patient has two older sibling, both of whom are alive and well. Social HistoryEM works as a sales representative for a fashion designer store in the state. She denies cigarette smoking but admits to social ETOH use and occasional marijuana use. She states that for the past 7 months, she has been sexually active with one male partner.
Patient also asserts that for contraception, she uses spermicide-coated condoms ROSGeneral Endorses mild fevers but denies chills, malaise, night sweats, fatigue, or recent weight changes CardiovascularPatient denies palpitations, claudication, chest pain, or orthopneaSkinEM denies changes in moles, rashes, itching, easy bruising, or bites RespiratoryDenies painful breathing, SOB, abnormal sputum production or cough. She does not recall even taking a TB skin testEyesDenies visual loss, double vision, or blurred vision. She states she has no history of cataracts or glaucoma.
Gastrointestinal Patient denies abdominal pain, difficulty swallowing, vomiting, intolerance to food, appetite changes, or stool changesEarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalPatient does report urgency, frequency, dysuria, odorous urine and suprapubic pain. She reports voiding at least 15 times daily. She nonetheless rebuts flank pain, hematuria and history of STIs. LMP 1 week ago, no heavy bleeding. She confides that she uses spermicide-coated condoms for contraception.
Nose/Mouth/ThroatEM denies nasal pain, congestion or other sinus problems. Refutes throat swelling or painMusculoskeletalDenies limits to ROM, swelling, muscle pain, or warm joints BreastShe denies discharge, redness, tenderness or any other breast changes NeurologicalPatient rebuts coordination difficulties, paralysis, tremors, seizures, or syncopeHeme/Lymph/EndoForegone PsychiatricDenies problems with concentration, nervousness, feelings of irritability, mood changes, or depressive symptoms OBJECTIVEWeight: 143lbs BMI: 23.1Temp: 37.3oCBP: 124/82Height: 5’6’’Pulse: 74Resp: 16General AppearanceCooperative Caucasian woman appearing her age, she seems in no distressSkinNo skin lesions observed upon physical examination HEENTHead normocephalic with normal hair distribution.
No facial swelling noted. Eyes: PERRLA; EOMI. Fundi benign. Ears: TMs intact with no erythema. Nose: Mucous membranes moist. Nasopharynx without erythema, exudates, or lesions. Mouth: Good dentition, no missing teethCardiovascularS1 & S2 normal without MRG. No carotid bruits. (-) JVDRespiratoryLungs CTA posteriorly and anteriorly GastrointestinalAbdomen soft and nontender. (+) bowel sounds BreastNo nipple retraction, lymphadenopathy, or nipple discharge GenitourinaryMild suprapubic tenderness noted with palpation. No inguinal hernias or CVA tenderness. Vaginal mucosa pink, no discharge, minimal rugae. Bimanual exam reveals no masses.
Patient reported tenderness over the bladder base after applying pressure to the anterior vaginal wall during the bimanual examination. Perineum intact without lesion. Rectovaginal exam – sphincter tone intact, septum intact; no tenderness or masses MusculoskeletalROM WNL without crepitus or pain Neurological Cranial nerves II-XII intact. (-) Romberg exam. Motor and sensory levels intactPsychiatricPatient alert and oriented ×
3. She appears to have normal affect and is able to follow commands Lab TestsUrinalysis – Yellow, cloudy; WBC 10–15 cells/hpf; RBC 1–5 cells/hpf; pH 5.0; protein 10 mg/dL; glucose (–); leukocyte esterase (+); trace blood; nitrite positive; many bacteriaPelvic ultrasound – Negative for uterine fibroids and ovarian cysts Urine culture—pendingSpecial Tests: None Diagnosis Diagnosis:N30.90-Cystitis, unspecified without hematuria (dysuria, urgency to urinate, and frequency of urination are all common signs of cystitis.
Tenderness over the bladder base after applying pressure to the anterior vaginal wall during the bimanual examination, mild suprapubic tenderness, and urinalysis findings also support cystitis as the definitive diagnosis)Differential Diagnosis:N39.0- Urinary Tract Infection: Urinary tract infections don’t always cause signs and symptoms, but when they do they may include a strong, persistent urge to urinate, burning sensation when urinating, passing frequent, small amounts of urine, urine that appears cloudy, red, bright pink or cola-colored (a sign of blood in the urine), strong-smelling urine, pelvic pain, in women (especially in the center of the pelvis and around the area of the pubic bone)
N10– Acute Pyelonephritis: Classic presentation in acute pyelonephritis is the triad of fever, costovertebral angle pain, and nausea and/or vomiting. These may not all be present, however, or they may not occur together temporally. Symptoms may be minimal to severe and usually develop over hours or over the course of a day. Infrequently, symptoms develop over several days and may even be present for a few weeks before the patient seeks medical care. Symptoms of cystitis may or may not be present to varying degrees.
These may include urinary frequency, hesitancy, lower abdominal pain, and urgency.N76.0– Vaginitis: Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. The cause is usually a change in the normal balance of vaginal bacteria or an infection. Reduced estrogen levels after menopause and some skin disorders can also cause vaginitis.PLAN Further testing; Urine Culture Medication: nitrofurantoin 100 mg twice per day for 5 days. Education: Patient education was fundamental during the encounter with this patient.
The patient received counseling about certain foods and substances that may trigger cystitis symptom flares including coffee and caffeinated beverages, soda, alcoholic beverages, citrus fruits and juices, spicy foods such as hot peppers, artificial sweeteners as well as food additives and preservatives. Patient also received information about self-care strategies that could help her in managing the symptoms of acute uncomplicated cystitis.
Some of these strategies included controlled fluid intake, pain relief strategies (e.g. warm sitz bath), gentle exercise, and physical therapy Follow-up: scheduled after 1 week. However, clinician advised the patient to return if the symptoms progress despite treatment or if they fail to resolve within 72 hours References Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Cook, J. (2015). Primary Care: A Collaborative Practice. Elsevier Health Sciences Codina, M. L. (2018). Family Nurse Practitioner Certification: Fast Facts and Active Questions. Third Edition.
New York: Springer Publishing Company Blunt, E. (2009). Family Nurse Practitioner: Nursing Review and Resource manual ( 4th ed., Vol 1).Silver Spring, MD: American Nurses Credentialing Center.www.epocrates.com Bethel, J. (2012). Acute pyelonephritis: risk factors, diagnosis and treatment. Nursing Standard, 27(5), 51– 56.
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