Posted: December 30th, 2021

Nursing essay

Operating head: SOAP NOTE 1

SOAP NOTE four

Title: R.T

Date: 03-16-2020

Age: 29

Intercourse: F

SUBJECTIVE

CC:

“I’m urinating on a regular basis, and it burns after I urinate”

HPI:

It is a 29-year-old African American girl presenting immediately to the clinic with persevering with complaints of dysuria, urgency to urinate, and frequency of urination. She states that she has just lately observed that her urine has a “foul and unsightly odor”. The affected person additionally complains of a gentle fever. She contends that bodily and emotional stress typically exacerbate the signs.

Medicines

None

PMH

Allergy symptoms: Affected person experiences no meals, environmental, or drug allergy symptoms

Remedy Intolerances: N/A

Persistent Sicknesses/Main traumas: No power diseases or main traumas

Hospitalizations/Surgical procedures: None

Household Historical past

Affected person’s father presently alive at age 61, identified with cardiac illness.

Mom handed away three years in the past from a tragic highway accident.

Affected person has two older sibling, each of whom are alive and effectively.

Social Historical past

EM works as a gross sales consultant for a clothier retailer within the state. She denies cigarette smoking however admits to social ETOH use and occasional marijuana use. She states that for the previous 7 months, she has been sexually lively with one male associate. Affected person additionally asserts that for contraception, she makes use of spermicide-coated condoms

ROS

Normal

Endorses gentle fevers however denies chills, malaise, night time sweats, fatigue, or latest weight adjustments

Cardiovascular

Affected person denies palpitations, claudication, chest ache, or orthopnea

Pores and skin

EM denies adjustments in moles, rashes, itching, straightforward bruising, or bites

Respiratory

Denies painful respiration, SOB, irregular sputum manufacturing or cough. She doesn’t recall even taking a TB pores and skin check

Eyes

Denies visible loss, double imaginative and prescient, or blurred imaginative and prescient. She states she has no historical past of cataracts or glaucoma.

Gastrointestinal

Affected person denies belly ache, issue swallowing, vomiting, intolerance to meals, urge for food adjustments, or stool adjustments

Ears

Denies ear ache, ear infections, or tinnitus

Genitourinary/Gynecological

Affected person does report urgency, frequency, dysuria, odorous urine and suprapubic ache. She experiences voiding no less than 15 instances each day. She nonetheless rebuts flank ache, hematuria and historical past of STIs. LMP 1 week in the past, no heavy bleeding. She confides that she makes use of spermicide-coated condoms for contraception.

Nostril/Mouth/Throat

EM denies nasal ache, congestion or different sinus issues. Refutes throat swelling or ache

Musculoskeletal

Denies limits to ROM, swelling, muscle ache, or heat joints

Breast

She denies discharge, redness, tenderness or every other breast adjustments

Neurological

Affected person rebuts coordination difficulties, paralysis, tremors, seizures, or syncope

Heme/Lymph/Endo

Foregone

Psychiatric

Denies issues with focus, nervousness, emotions of irritability, temper adjustments, or depressive signs

OBJECTIVE

Weight: 143lbs BMI: 23.1

Temp: 37.3oC

BP: 124/82

Peak: 5’6’’

Pulse: 74

Resp: 16

Normal Look

Cooperative Caucasian girl showing her age, she appears in no misery

Pores and skin

No pores and skin lesions noticed upon bodily examination

HEENT

Head normocephalic with regular hair distribution. No facial swelling famous. 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 lacking tooth

Cardiovascular

S1 & S2 regular with out MRG. No carotid bruits. (-) JVD

Respiratory

Lungs CTA posteriorly and anteriorly

Gastrointestinal

Stomach delicate and nontender. (+) bowel sounds

Breast

No nipple retraction, lymphadenopathy, or nipple discharge

Genitourinary

Gentle suprapubic tenderness famous with palpation. No inguinal hernias or CVA tenderness. Vaginal mucosa pink, no discharge, minimal rugae. Bimanual examination reveals no lots. Affected person reported tenderness over the bladder base after making use of stress to the anterior vaginal wall in the course of the bimanual examination. Perineum intact with out lesion. Rectovaginal examination – sphincter tone intact, septum intact; no tenderness or lots

Musculoskeletal

ROM WNL with out crepitus or ache

Neurological

Cranial nerves II-XII intact. (-) Romberg examination. Motor and sensory ranges intact

Psychiatric

Affected person alert and oriented × three. She seems to have regular have an effect on and is ready to observe instructions

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 (+); hint blood; nitrite optimistic; many micro organism

Pelvic ultrasound – Unfavourable for uterine fibroids and ovarian cysts

Urine tradition—pending

Particular Checks: None

Analysis

Analysis:

· 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 course of the bimanual examination, gentle suprapubic tenderness, and urinalysis findings additionally help cystitis because the definitive prognosis)

Differential Analysis:

· N39.Zero- Urinary Tract An infection: Urinary tract infections do not at all times trigger indicators and signs, however after they do they could embody a robust, persistent urge to urinate, burning sensation when urinating, passing frequent, small quantities of urine, urine that seems cloudy, crimson, shiny pink or cola-colored (an indication of blood within the urine), strong-smelling urine, pelvic ache, in girls (particularly within the middle of the pelvis and across the space of the pubic bone)

· N10– Acute Pyelonephritis: Traditional presentation in acute pyelonephritis is the triad of fever, costovertebral angle ache, and nausea and/or vomiting. These could not all be current, nonetheless, or they could not happen collectively temporally. Signs could also be minimal to extreme and normally develop over hours or over the course of a day. Sometimes, signs develop over a number of days and will even be current for a number of weeks earlier than the affected person seeks medical care. Signs of cystitis could or might not be current to various levels. These could embody urinary frequency, hesitancy, decrease belly ache, and urgency.

· N76.Zero– Vaginitis: Vaginitis is an irritation of the vagina that can lead to discharge, itching and ache. The trigger is normally a change within the regular stability of vaginal micro organism or an an infection. Diminished estrogen ranges after menopause and a few pores and skin issues can even trigger vaginitis.

PLAN

· Additional testing; Urine Tradition

· Remedy: nitrofurantoin 100 mg twice per day for five days.

· Schooling: Affected person schooling was basic in the course of the encounter with this affected person. The affected person obtained counseling about sure meals and substances which will set off cystitis symptom flares together with espresso and caffeinated drinks, soda, alcoholic drinks, citrus fruits and juices, spicy meals equivalent to scorching peppers, synthetic sweeteners in addition to meals components and preservatives. Affected person additionally obtained details about self-care methods that would assist her in managing the signs of acute uncomplicated cystitis. A few of these methods included managed fluid consumption, ache reduction methods (e.g. heat sitz tub), mild train, and bodily remedy

· Observe-up: scheduled after 1 week. Nonetheless, clinician suggested the affected person to return if the signs progress regardless of remedy or in the event that they fail to resolve inside 72 hours

References

Buttaro, T. M., Trybulski, J., Polgar, B.P. & Sandberg-Prepare dinner, J. (2015). Major Care: A Collaborative

Observe. Elsevier Well being Sciences

Codina, M. L. (2018). Household Nurse Practitioner Certification: Quick Information and Lively Questions. Third

Version. New York: Springer Publishing Firm

Blunt, E. (2009). Household Nurse Practitioner: Nursing Evaluate and Useful resource guide ( 4th ed., Vol 1).Silver

Spring, MD: American Nurses Credentialing Middle.

www.epocrates.com

Bethel, J. (2012). Acute pyelonephritis: threat components, prognosis and remedy. Nursing Normal, 27(5), 51–

56. Retrieved from

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