Genitourinary SOAP Note

Genitourinary SOAP Note

Patient Information:

Patient Initials: T.S.                Age: 32 years                Gender: Female       Race: African American

SUBJECTIVE DATA:

Chief Complaint (CC): Increased frequency and pain with urination

History of Present Illness (HPI): T.S. is a 32-year-old African American female who presents to the facility with increased frequency and pain on urination for the past two days. She reports experiencing pain in the lower back and a burning sensation when urinating. T.S. rates the pain on a scale of five out of ten. She noticed that her urinary frequency has increased since she used to urinate twice a day and once at night and is currently urinating five times a day. T.S. is experiencing a sudden urge to urinate that is difficult for her to control. She feels pain during urination, which she tries to control by trying to have a slow urine stream during urination.

Current Medications: Ibuprofen 400mg TDS PRN

Allergies: T.S. has no known drug or food allergies.

Past Medical History (PMH): T.S. experiences dysmenorrhea that she manages using ibuprofen. She delivered her son via spontaneous vaginal delivery in 2011. She was vaccinated against Covid-19 in September and October 2020.

Surgical History: T.S. underwent a tonsillectomy in 2001 and an appendectomy in 2020.

Social History: T.S. is divorced and lives with her ten-year-old son. She works as a psychology lecturer. She frequently volunteers at a children’s home during the holidays and weekends. She maintains a healthy lifestyle by being physically active and eating a balanced diet. She plays badminton at the college where she is a lecturer. She enjoys traveling and visiting new places with her friends. T.S. also drinks alcohol mostly during social events and does not smoke. In addition, she has comprehensive medical coverage for herself and her son.

Family History: T.S. is the lastborn of two children and the mother of a ten-year-old son. Her son suffers from migraines. T.S.’s elder brother is in good health. Her parents are in good health. However, her paternal grandparents died of hypertensive complications. Her maternal grandmother died in a road traffic accident, while his maternal grandfather is alive with diabetes.

Review of Systems:

General: She reports daytime sleepiness and disturbances and denies chills, fever, fatigue, headaches, night sweats, day sweats, weight gain, or weight loss.

HEENT/Neck: T.S. denies difficulty swallowing and rhinorrhea. She also refuses changes in vision, double vision, itchy eyes, blurry vision, painful eyes, light sensitivity, and visual loss. The patient also denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion. Her last eye and dental examination were six months ago.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, difficulty breathing, or sputum production.

Cardiovascular/Peripheral Vascular: T.S. denies lightheadedness when standing, paroxysmal nocturnal dyspnea, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Gastrointestinal: Reports loss of appetite. Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Reports painful urination, frequent urination, and urinary urgency. She denies urinary incontinence, dribbling, decreased stream, and blood in the urine. She also prohibits vaginal discharge or itching. Her last monthly period was 19/11/2022.

Musculoskeletal: T.S. reports flank pain. She denies muscle pain, back pain, stiffness, or joint pain.

Neurological: Denies hemiparesis, gait disturbance, body weakness, auras, dizziness, syncope, lightheadedness, disequilibrium, loss of coordination, scotoma, facial flushing, memory loss, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, changes in thinking patterns, spells of blindness, or dizziness.

Hematologic: Denies bleeding, bruising, or anemia.

Lymphatics: Denies splenectomy or enlarged nodes.

Psychiatric: Denies depression, increased irritability, history of suicidal thoughts, anxiety, bipolar disorder, confusion, problems with memory and concentration, or any other mental health problem.

Skin: Denies swelling, redness, tenderness, rashes, itching, and ulceration.

Endocrinology: Denies weight gain, hair loss, hot flashes, and weight loss.

Allergies: Denies rhinitis, eczema, asthma, or hives.

Reproductive: Heterosexual. Sexually active.

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 116/74 mmHg, HR-102 bpm, SPO2- 98% on room air, Temp 37.3°C, RR-16 bpm, Height 168cm, Weight 56kgs, BMI 19.8.

General: The patient is cooperative, hygienic, and well-dressed. She is well-oriented with time, people, and her surroundings.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, and blurry vision.

Neck: The neck has a limited range of motion in all directions, normal symmetry, standard length, and no palpable lymph nodes.

Respiratory: On palpation, there is no tenderness or palpable mass. On auscultation, normal breathing sounds without wheezing or audible breathing sounds—no chest deformities.

Heart/Peripheral Vascular: On palpation, average heart size and standard heart location. On auscultation, average heart rate, regular rhythm, and no murmurs. Normal extremities.

Abdomen: Denies abdominal pain on palpation. The liver and spleen are of average size and have normal tenderness and consistency.

Genital/Rectal: Rectal exam was not conducted. No vaginal discharge. No adnexal tenderness. Clear urine. The cervix appears normal.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: Normal mood, memory, awareness of context, and orientation to time and place.

Skin: Her skin tone is appropriate for her ethnicity. On pinching the skin, the skin slowly returns to its normal position.

Diagnostic results:

ASSESSMENT:

Human chorionic gonadotropin test: this is recommended since pregnant women are highly susceptible to urinary tract infections (Bono et al., 2022). Results show a negative HCG test.

Urinalysis: Recommended to test for pyuria and proteinuria. Results showed a white blood cell count of 12WBCs/mL and low-grade proteinuria. No candida casts in the urine.

Pap smear: Results showed a normal cervix.

Complete blood count: Results show average white blood cell count.

Computed tomography is recommended to rule out pyelonephritis (Belyayeva & Jeong, 2022).

Differential Diagnosis (DDx):

Urinary tract infection: Urinary tract infections (UTIs) occur primarily in females compared to males (Bono et al., 2022). Females diagnosed with UTI usually present with dysuria, suprapubic tenderness, blood in urine, flank pain, urinary frequency, chills, a sensation of bladder fullness, urinary urgency, lower abdominal discomfort, fever, and malaise. UTI is a differential and primary diagnosis since T.S. presents with dysuria, urinary frequency, urinary urgency, and flank pain. Urinalysis shows proteinuria and pyuria. An average WBC count shows uncomplicated UTI (Bono et al., 2022).

Chlamydia: Patients diagnosed with chlamydia usually present with dysuria, abdominal pain, fever, vaginal discharge, dyspareunia, history of sexual activity, and fever (Mohseni et al., 2022). Risk factors for chlamydia seen in T.S. include non-white race and having a new sexual partner. Chlamydia is a differential diagnosis since T.S. is an African American with a new sexual partner for the past three months who presents with dysuria, flank pain, and a history of sexual activity. Urinalysis showed no candida cast in urine and no abnormal vaginal discharge.

Acute pyelonephritis: Acute pyelonephritis is caused by bacteria that can cause urinary tract infections reaching the kidney through the bloodstream (Belyayeva & Jeong, 2022). Acute pyelonephritis is a differential diagnosis since T.S. presents with signs of urinary tract infection. Computed tomography rules out pyelonephritis as a primary diagnosis.

Urethritis: Patients diagnosed with urethritis usually present with dysuria and a burning sensation on urination, as seen in T.S. (Young et al., 2022). However, a physical examination ruled out urethritis due to the presence of a normal cervix and lack of abnormal vaginal discharge.

Vaginitis: Vaginitis is common in sexually active women and women of childbearing age (Hildebrand & Kansagor, 2022). It is a differential diagnosis because T.S. is a 32-year-old sexually active female with a new sexual partner for the past three months—the absence of abnormal vaginal discharge and no candida cast in urine rule out vaginitis.

References

Belyayeva, M., & Jeong, J.M. (2022). Acute Pyelonephritis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519537/.

Bono, M.J., Leslie, S.W., & Reygaert, W.C. (2022). Urinary Tract Infection. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470195/.

Hildebrand JP, Kansagor AT. (2022) Vaginitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470302/

Mohseni, M., Sung, S., & Takov, V. (2022). Chlamydia. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537286/.

Young A, Toncar A, Wray AA. (2022). Urethritis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537282/.

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GENITALIA ASSESSMENT

Genitourinary Assessment

CC: Increased frequency and pain with urination

HPI:

T.S. is a 32-year-old woman who reports that for the past two days, she has had dysuria, frequency and urgency. He has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.

Medical History:

None

Surgical History:

• Tonsillectomy in 2001
• Appendectomy in 2020

Review of Systems:

• General: Denies weight change, positive for sleeping difficulty because of the flank pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite

Objective 

VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.

Pelvic Exam:

• mild tenderness to palpation in the suprapubic area
• bimanual pelvic examination reveals a normal-sized uterus and adnexa
• no adnexal tenderness.
• No vaginal discharge is noted.
• The cervix appears normal.

Diagnostics: Urinalysis, STI testing, Pap smear

Assessment:

• UTI
• STI

To Prepare

• Please make sure to write this assignment up in narrative form

• Based on the Episodic note case study:
  • Consider what history would be necessary to collect from the patient in the case study.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Lab Assignment

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

Address all of the following questions in great detail. Analyze all the information that you have been provided with.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Does the subjective and objective information support the assessment? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.