Abnormal Urinalysis SOAP Note
Develop a SOAP Note for a patient you encountered with and abnormal urinalysis test. Explain the meaning of the laboratory diagnostic and its impact on the treatment plan. How will you decide if the patient has a bladder or kidney problem?
Discussion 5: Abnormal Urinalysis Test
SUBJECTIVE
Chief Complaint: Lower abdominal pain, dysuria, urgency, and sensation of incomplete voiding
History Patient Illness: A 42-year old female patient presented to the clinic complaining of lower abdominal pain and pelvic pain. The patient had a two-day history of increased urinary frequency, incomplete voiding, burning, discomfort, and pain during urination. Over the last week, she has also been experiencing lower abdominal pain that radiates to her back and vaginal discharge. She has also noted a brown foul-smelling discharge after having unprotected sexual intercourse. She is married and has had one sexual partner for the last decade. She complains of symptoms similar to previous UTIs. The patient states that she has a history of UTIs that have recurred in the last four months despite taking medication. Her symptoms are aggravated when she does not drink water during the day. The symptoms are relieved after ingesting water, cranberry juice, and medication. Previously, she took Sulfamethoxazole-trimethoprim, Ciprofloxacin, and phenazopyridine to relieve similar symptoms.
Allergies: Penicillin (rash)
Family History:
The patient is married with three healthy children. Mother is alive but has hypertension and diabetes type 2. Father deceased due to lung cancer.
Social History:
The patient is a social drinker. She has a 12-pack/ year history having smoked 1 pack daily for the last 12 years.
Past History
Childhood Illnesses: Measles, mumps, chickenpox, and rheumatic fever.
Adult Illnesses: Recurrent urinary tract infections, hypertension, emphysema, and pneumonia
Past Surgery: Tubal ligation five years ago.
Health Maintenance: Up-to-date immunizations
Review of Systems:
General: Moderate distress. No recent changes in weight, fever, weakness, and fatigue.
Skin: Denies rashes, itching, lumps, dryness, sores, changes in hair, skin or nails
HEENT: Head: Denies head injury, headache, dizziness, or lightheadedness
Eyes: Normal vision, denies excessive tearing, pain, redness, spots, flashing lights, cataracts, and glaucoma.
Ears: Normal hearing, denies tinnitus, earache, infection, vertigo, and discharge.
Nose: Denies colds, discharge, itching, nosebleeds, nasal stuffiness, and sinus trouble
Throat: Healthy teeth and gums, denies bleeding gums, dentures, sore tongue, hoarseness, dry mouth, and sore throats.
Neck: Denies swollen glands, pain, lumps, tenderness and stiffness
Breasts: Denies breast lumps, discomfort, pain, and nipple discharge.
Respiratory: Denies cough, sputum, hemoptysis, dyspnea, wheezing, and pleuritic pain.
Cardiovascular: Denies heart trouble, rheumatic fever, edema, murmurs, chest discomfort, pain, palpitations, and orthopnea.
Gastrointestinal: Confirms abdominal pain and normal bowel movements. Denies trouble swallowing, low appetite, heartburn, nausea, rectal bleeding, hemorrhoids, diarrhea, constipation, food intolerance, excessive belching. No past history of hepatitis, jaundice, gallbladder or liver trouble.
Musculoskeletal: Lower back pain, but denies muscle and joint pain, swelling, backache, stiffness, redness, tenderness, and limitation of motion.
Psychiatric: Denies anxiety, tension, mood, nervousness, depression, changes in memory, suicidal ideations, plans and attempts.
Neurologic: Denies change in moods, attention, orientation, insight, memory, and judgment; dizziness, fainting, weakness, vertigo, paralysis, loss of sensation, tingling, seizures, tremors and involuntary movement.
Endocrine- No thyroid trouble, excessive sweating, polyuria, heat/cold intolerances, excessive hunger or thirst, changes in shoe or glove size.
Urinary: Confirms urgency, dysuria, pain during urination, polyuria, nocturia, hematuria, urinary infections, kidney/flank pain, suprapubic pain, incontinence, cloudy, and foul-smelling urine.
Pertinent Medications
Sulfamethoxazole-trimethoprim160 mg orally each 12 hours, Ciprofloxacin 250 mg 2 times daily, phenazopyridine, 200 mg 3 times daily.
OBJECTIVE
Physical Examination
Constitutional: Patient is in moderate distress, appears well nourished, well-groomed, and well developed for her age.
Temp: 97.7, HR 84, RR 24, O2 sat 100% on RA.
Vital Signs
Blood pressure 110/80, heart rate 75, respiration rate 18, Temperature 99.8 F, Weight 122, Height 5’ 3”, PO2 95% on room air.
HEENT: Head normocephalic, PERRLA, EAC clear, PERRLA, no nasal obstruction, throat is clear, moist mucus membrane, scleral icterus, no lesions, and normal size tonsils
Neck: No cervical lymphadenopathy, masses, nodules, or JVD.
Heart: Regular heart rate and rhythm, no palpations, gallops, or murmurs
Skin: Warm and dry, no abscesses, rashes, lesions, or moles
Respiratory: Lungs sound clear 4, no wheezing
Gastrointestinal: Soft and flat abdomen, bowel sounds present in four quadrants, tenderness on deep and light palpations mid lower abdomen section, no rebound, distension, or guarding
Musculoskeletal: No swelling in tissue, no edema, discoloration, noted flank pain
Neurological: Alert, speech clear, oriented 4, and normal gait
Psychiatric: Anxiety
Laboratory tests: Laboratory tests were performed to diagnose the UTI, identify the bacteria causing the infection, and determine the best treatment. A clean-catch and midstream urine sample for urinalysis. A urine culture was done to confirm the positive urinalysis due to recurring UTI. Also, susceptibility testing was done to ascertain the antimicrobial drug effective for treating the UTIs.
ASSESSMENT
Diagnosis: Recurrent bacterial UTI
The abnormal urinalysis revealed infectious process in urinary tract system exhibiting: cloudy appearance, bacterial overgrowth, elevated nitrite levels, positive leukocyte esterase, alkaline pH, hematuria, and urine sediments of RBCs, mucus, and WBCs.
Differential Diagnosis:
- Tumors of the renal system: The mass could not be visualized on cystoscopy and verified by pathologic biopsy specimen diagnosis.
- Vaginitis: Negative microscopic urinalysis, urine dipstick, urine cultures, and positive vaginal culture. The direct exam yields budding hyphae and yeasts the use of potassium hydroxide enhances the recovery of these fungal elements and presence of normal vaginal flora.
- Pyelonephritis (Upper UTI) Patient does not exhibit signs of sepsis like chills and fever, presence of WBC casts in the urine, flank as well as tenderness of the costovertebral angle on examination.
PLAN
The patient will continue antibiotic therapy TMP-SMX 8 to 10 miligram/kilogram/day IV in 2 equally divided dosages every 12 hours for 14 days. In addition, the patient will continue using cranberry capsules (400 mg PO twice daily) to decrease the frequency of recurrence of the UTI. Following the completion of the prescribed antibiotic treatment, follow-up cultures can be gotten to guarantee complete eradication of the pathogen due to the history of recurrent infections. Additional medication phenazopyridine 200 milligram thrice daily for a maximum 2 days was prescribed to relieve pain, frequency, burning, and urgency. Patient education will focus on teaching the female patient to stop recurrence of UTI. The patient was advised to complete the course of antibiotic therapy even after subsiding of symptoms and increase water intake to eight 8-ounce glasses daily to flush out bacteria. She will be advised to empty her bladder totally, probably by double voiding. The patient is advised to keep a diary of infections and treatment response which will be reviewed annually to track problems associated with medication. Lastly, the patient should notify the doctor if symptoms like fever, flank pain, hematuria, or no response to the prescribed treatment.
References
Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.
Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.