Pain and difficulty urinating

 

 

 

Create a soap note based on this patient and use the template provided.

35-year-old female patient who presented with flank pain and difficulty urinating. The primary challenge was differentiating between several potential diagnoses that shared overlapping symptoms. However, the success of this case lay in developing a comprehensive plan of care based on a thorough assessment and evidence-based guidelines.

To begin, the patient exhibited symptoms including right-sided flank pain that radiated to the lower abdomen, dysuria, increased urinary frequency, a low-grade fever of1 00.6 F, nausea without vomiting, and mild costovertebral angle tenderness. The assessment process involved taking a detailed history, conducting a physical examination, and ordering laboratory tests such as urinalysis, urine culture, and complete blood count. An abdominal ultrasound was also performed to check for possible kidney stones or other structural abnormalities.

Three differential diagnoses were considered. The first was urinary tract infection (UTI), which was deemed the most likely diagnosis due to the presence of dysuria, frequency, and low-grade fever. UTIs are common in women of reproductive age and can present with these symptoms (Medina & Castillo-Pino, 2019). The second possibility was pyelonephritis, considered due to the flank pain and fever, indicating an upper UTI that may have ascended to the kidneys. The third differential diagnosis was nephrolithiasis (kidney stones), given the acute onset of flank pain, however, the absence of severe colicky pain made this less likely.

The plan of care involved antibiotic therapy pending culture results to treat the suspected UTI. Moreover, pain management included NSAIDs to alleviate discomfort. The patient was also advised to increase fluid intake to help flush out any infection and prevent dehydration. A follow-up appointment was then scheduled for 72 hours later to monitor symptom improvement and adjust treatment, if necessary, based on culture results.

Health promotion interventions for this patient focused on educating her about proper hygiene practices to prevent future UTIs, advising on adequate hydration, discussing sexual health practices that may reduce UTI risk, and encouraging regular health check-ups and prompt reporting of any urinary symptoms.

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.

Sample Solution

SOAP Note

Patient: [Patient Name]
Date: [Date of Visit]
Time: [Time of Visit]
Age: 35
Sex: Female

S – Subjective:

Patient presents with complaints of right-sided flank pain radiating to the lower abdomen, dysuria, increased urinary frequency, low-grade fever (100.6°F), nausea without vomiting, and mild costovertebral angle tenderness.

O – Objective:

  • Vital Signs: Temperature 100.6°F, BP [Blood Pressure], HR [Heart Rate], RR [Respiratory Rate]

  • Physical Exam: Mild costovertebral angle tenderness noted on the right side. Otherwise, examination is unremarkable.

  • Labs: Urinalysis and urine culture ordered. Complete blood count ordered.

  • Imaging: Abdominal ultrasound performed to rule out kidney stones or structural abnormalities.

A – Assessment:

Differential Diagnoses:

  1. Urinary Tract Infection (UTI): Most likely diagnosis due to dysuria, frequency, and low-grade fever. Common in women of reproductive age.

  2. Pyelonephritis: Considered due to flank pain and fever, suggesting an upper UTI potentially affecting the kidneys.

  3. Nephrolithiasis (Kidney Stones): Less likely due to the absence of severe colicky pain.

P – Plan:

  • Medical Management: Antibiotic therapy initiated pending culture results to treat suspected UTI. NSAIDs prescribed for pain management.

  • Hydration: Patient advised to increase fluid intake to help flush out the infection and prevent dehydration.

  • Follow-Up: Follow-up appointment scheduled in 72 hours to monitor symptom improvement and adjust treatment based on culture results.

Health Promotion:

  • Hygiene: Educated on proper hygiene practices to prevent future UTIs.

  • Hydration: Advised to maintain adequate hydration.

  • Sexual Health: Discussion regarding sexual health practices to reduce UTI risk.

  • Routine Care: Encouraged to seek regular health check-ups and report any urinary symptoms promptly.

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