Mrs PT 65 yrs Female Soap Note

Mrs PT 65 yrs Female Soap Note

SOAP Note Form
S/ Identifying Information:   (initials, age/DOB, gender, reliability) Family Hx:
Mrs. P. T.65 yrs.Female

Reliable Historian

Paternal Grandmother and Grandfather are deceased with no known health histories. Maternal Grandfather, 105, is partially blind, diabetic, and hypertensive. Maternal Grandmother died at 65 of uterine cancer was diabetic and hypertensive. Faith died in a road accident at 40 was diabetic and hypertensive. Mother, 81, has diabetes. Brother, 48, is obese and diabetic. Sister, 44, is healthy with no compilations. Mrs PT 65 yrs Female Soap Note
Personal/Social Hx :
Chief Complaint/RFE: Denies alcohol intake, smoking, or illicit drug abuse.Marriage status: widow for the last five years.Living conditions: Lives alone in the house, son lives in the neighborhood and occasionally visits

Occupation: She is a retired lab technician

Hobbies: walking, hiking (limited due to old age), walking, reading books.

“I have been feeling pain when urinating.”
Hx Present Illness: (7 Variables but do not list as such)
Mrs. P. T. reports burning pain when urinating. She reports that her pain began three days ago as a mild discomfort which she rated 1/10 on a pain rating scale. The pain is not continuous, and it only appears during urination. The pain gradually increased, and she rates the current pain at 8/10. The pain interferes with complete urination hence voiding small frequent urine volumes causing more pain. The urine is clear but has a strong, pungent smell. The pain has also caused hesitancy when voiding. She complains she more frequently feels the urge to urinate after taking coffee or tea, and thus she avoids them and takes clear fluids such as water. She took some painkillers, paracetamol 1g PO, which provided temporary ineffective relief, so she stopped taking them. The pain is accompanied by inguinal lymph nodes pain and swelling. Pain persists after voiding, and the pain is aggravated by walking or stretching the abdomen, making daily living activities difficult. She reports fever denies sexual recent sexual contact, swimming, and any trauma to the genitalia. She denies any other symptoms.
CURRENT HEALTH
Medications:  Insulin Regular Human/ neutral insulin/ soluble insulinInjectable insulin, 10 IU TDS. Indication: Diabetes Glucose regulation in a diabetic patient. class: HAntidiabetics, short-acting insulins. MOA: Insulin regulates blood sugar by stimulating peripheral glucose uptake into the cells, primarily the muscle cells and lipocytes. It also inhibits the production of glucose and its release by the liver. Insulin increases glycogenesis and the conversion of glucose into other forms and stimulates its storage. These actions reduce blood sugar in the circulatory system. Side effects: sweating, shakiness, hunger (hypoglycemia), tachycardia, tingling sensations, lured vision, confusion, attention deficit, mood changes, sleepiness, weakness, fatigue, and severe symptoms such as loss of consciousness, seizures, nightmares, and loss of coordination ((Świątoniowska et al., 2019). Patient education: Take your blood glucose reading before injecting insulin, use a different region every time to inject the insulin, avoid injecting a similar place twice consecutively, do not inject the medicine into an injured area with a bruise, scar, lump, scaly, or pitted. Eat a meal within thirty minutes of injecting regular insulin (Janež et al., 2020 Mrs PT 65 yrs Female Soap Note).
Allergies: Denies any food or drug allergy. Allergic to pollen, dust, and cats. Manifestation incl: sneezing, wheezing, running nose, coughing, headache, and red, itchy, and watery eyes
Last PE & Screenings: Last took a comprehensive PE 3 months ago, normal PAP. Reports a normal HgBA1c, foot, eyes, and other exams
Immunization Status: Reports having all childhood immunizations UPTD, COVID 19, tetanus, flu shot, and HPV vaccines
LMP & Birth Control (if applicable) Menopause at 46
PMH
Illnesses & Trauma:  Road accident at 35, broke both legs and prolonged immobility, hx of Diabetes controlled with dieting and insulin, no other illnesses
Hospitalizations/Surgeries: Hospitalized for fracture reduction, mobilization, and monitoring for 13 days. Had three caesarian sections, each two days hospitalization. Denies other hospitalizations
OB Hx/Sexual Hx: Sexually inactive since husband’s death, four years ago. History of treated genital warts at 32
Emotional/Psy Hx: Reports mild depression and loneliness, denies anxiety and psychiatric disorders.
REVIEW OF SYSTEMS
General: Reports fever, pain, discomfort, and mild depression. Denies chills, night sweats, recent drastic weight loss, or weight gain.
Nutrition Cooks her food at home. Eats three meals and recommended snacks a day. Eats food low on salt, cholesterol-free, with no caffeine intake.
Skin/ Reports slight acne and hyperpigmentation. Denies skin rashes, lesions, tenderness, pain, or massesHair/Nails: Denies infected, painful, brittle, discolored nails. Denies hair loss, excessive growths, or brittle hair
Head: Denies recent headaches, injuries, or concussions. Had a concussion at 32Ears: Reports some hearing loss. Denies otorrhea, discharge, vertigo, tinnitusEyes: Current visual changes but uses corrective lenses. Denies blurry vision, photophobia, pain, dryness, itchiness, or diplopia

Nose: Denies smell sense changes, sinus pain, stuffiness, nasal drainage, congestion, sneezing

Throat: Denies voice changes, dysphagia, gum pain/bleeding, toothaches, mouth ulcers or lesions, dysphagia.

Breasts: Denies breast pain, masses, nodules, pain, tenderness, galactorrhea, or discharge
Respiratory: Reports some non-productive cough, denies dyspnea, cyanosis, wheezing,
CV Denies chest pain, palpitations, fatigue at rest or little activity, edema, orthopnea, body weakness.Peripheral vascular Denies leg pain, swelling, redness, or weakness.
GI: Reports excruciating pain in the lower abd., pain voiding. Denies nausea, vomiting, hemorrhoids, hemoptysis, loss of appetite, melena, hematemesis, heartburn, hematochezia, or stool color changes
GU: Reports severe dysuria, increased frequency, hesitancy, flank pain, suprapubic pain, and loss in stream force. Denies vagina discharge, rashes, or lesions. Mrs PT 65 yrs Female Soap Note
MSK: Reports mild joint pain. Denies limited ROM, joint stiffness, swelling, redness, bone deformities
Psych: Reports mild depression and loneliness. Denies anxiety, mood changes, poor concentration, agitation, insomnia, hypersomnia, irritability, suicidal ideations, or attempts.
Neuro  Denies fainting, seizures, malaise, tremors, memory loss, coordination difficulties, paralysis, or paresthesia.
Lymph/Heme/Endocrine: Reports pain in the inguinal lymph node. Denies other lymph pain. Denies bruising, diagnosed anemia, heat or cold intolerance, thyroid pain or tenderness, or polydipsia. Reports occasional polyphagia and polyuria
O/ Physical Exam: T: 37.1      P:   139/88     R:   88     BP:    92      HT:  160cm       WT:   58kg      BMI: 22.7
General: Patient in generally fair condition, mildly stressed, fully oriented to person, time, space, and occasion, well dressed and groomed
Skin: slight acne and hyperpigmentations scattered over the face, old age wrinkles, no apparent trauma, lesions, rashes, swellings, breakages, or tenderness
Head: normocephalic, grey hair evenly distributed, no lesions, swelling, or masses. No tenderness, scars, or visible trauma.
Eyes: PERRLA bilaterally, visual acuity 20/20 right and left eye, no corrective lenses. Sclera white, pink conjunctiva No erythema, draining clear fluid (tears), no apparent injury, eyelashes pre4sent and raised. Ears: No swelling, rashes, or lesions. Ear drug grey and shiny, no drainage, erythema, or masses. No pain on palpation. Positive whisper test – hearing intact.Nose: Intact membrane, no nasal drainage, nasal mucosa pink, no inflammation. No pain on palpation of the sinuses, sense of smell intact,
Throat & Mouth: Ovule midline, taste intact, gag reflex present. No gum redness, bleeding, or pain. Lips pink, no dryness,Neck: Symmetrical neck, no apparent masses, lesions, tenderness. No pain on palpation, unpalpable cervical lymph nodes, trachea midline, unpalpable thyroids, symmetrical movement with swallowing, full range of motion
Breasts/Chest: breast exam deferred
Lungs: symmetrical chest movement, no accessory muscle use, quiet breathing with no crackles or wheezes on breathing, respiratory rate 18, resonance on percussion.
Heart/ perip vascular: Jugular vein not distended, no carotid bruits, carotid pulse 92. S1 and S2 heart sounds, no S3 or heart murmurs. Capillary refill <2 sec. No calf pain, no edema, femoral and radial pulse 92
Abdomen: Round, CS scars with no other scars, no flank discoloration. Bowe sounds in all quadrants, no hepatomegaly, spleen, and kidney not palpable, tenderness and guarding on light palpation of the lower abdomen.
Genitalia/Rectum; deferred
Lymph: inguinal lymph nodes inflamed. Cervical, axilla, sub clavicular lymph nodes not palpable.
MSK: Posture and balance intact, all reflexes intact. Appreciable biceps, trapezius, triceps, hamstrings, and calf muscles. Has a tight hand grip
Neuro: Intact cranial nerves, posture, and balance appreciable,  good speech, follows all instructions, intact long-term and short-term memories.
Medical Dx: (2max) R30.0 Dysuria Rule Outs (only if applicable):
Health Profile:
Age/gender/racial risks:  Elderly  + Female: exposed to health conditions common in old age. Older adults generally have lower. Females are more exposed to UTIs due to a shorter urethra.
Pertinent Positives:(1DX) Severe dysuria, increased frequency, hesitancy, flank pain, suprapubic pain, loss in stream force, and pain in the inguinal lymph node
personal/family:  None
screening needs:  None
Pertinent NegativesShe denied recent sexual intercourse, history of STIs, persistent pain, trauma to the pelvis, vagina discharge counseling needs:  None
Immunization/chemo needs:  None
Differential DX: (3-5): A64 STIs, N30. 9 Cystitis,N77.1 Vaginitis, Z18. 9 Foreign body (for example kidney stone), S39.93XA Pelvic Trauma Alteration in Health Prevention R/T:
Screening deficits: None
Counseling deficits: None
Nursing DxImpaired urinary elimination related to pain during urination as evidenced by frequent urination of small volumes. Mrs PT 65 yrs Female Soap Note Immunization/chemo deficits: None
I. PLAN:  Do separate sections in the plan  to include: Max 1-2 pagesDiagnostics:

Dysuria in Uncomplicated Cystitis

Medications/Treatments:

Nitrofurantoin 100mg twice daily for five days, Trimethoprim 200mg twice daily, Fosfomycin oral 2g STAT dose, and paracetamol 1g TDS 3 days. Cleaning the perineum with clean water only at least three times every day.

Urinalysis, blood culture, and cytology to confirm or rule out the diagnosis.

Education:

Take copious amounts of water. Wipe yourself from the front to back after voiding. Void often, avoid hesitancy which can exacerbate an infection and delay wound healing. Always observe the color and smell of your urine. Come back if the pain persists, urine changes color, or there is blood or urethral discharge after the treatment regimen.

Follow-up:

To come again after two weeks for follow-up care. Should come back if she stops blood in urine or pain increases before the return date.

Referrals:

Refer for lab works such as culture and sensitivity and cancer screening to rule out other causes such as neoplasms.

Prevention Plan: Stay hydrated urinate anytime you feel the urge. Wipe from the front to the back. Avoid washing the perineum with soap; clean with clean water alone at least three times a day.

II. Rationale: ( Max 2 pages)Dysuria is the diagnosis of choice majorly due to the under involvement of vaginal and other reproductive system structures. The woman also reports no sex encounter recently, hence ruling out STIs (Bradley et al., 2019). The pain may result from infections of the urinary tract without kidney involvement. Nitrofurantoin is the drug of choice for treating urinary tract infections due to difficulty with antibiotics treatment in older adults (Bradley et al., 2019). In addition, the drug of choice must have active metabolites excreted through the kidney. Additional tests such as blood culture will help identify the causative organisms hence effective treatment. It will also help rule out other conditions (Kornfält et al., 2021)
III. Patho: (Max 2 pages) Dysuria is common among older females due to various reasons. The most common cause of dysuria is cystitis, followed by STIs. Infection in the female reproductive system results from a short urethra and decreased immunity (Bradley et al., 2019). Infections cause lacerations of the urinary tract, and the acidic urine causes pain as it passes the exposed areas. Adherence of urethra and bladder walls after emptying causes excruciating pain hence the reluctance to void common in dysuria.

 Mrs PT 65 yrs Female Soap Note References

  • Janež, A., Guja, C., Mitrakou, A., Lalic, N., Tankova, T., Czupryniak, L., … & Smircic-Duvnjak, L. (2020). Insulin therapy in adults with type 1 diabetes mellitus: a narrative review. Diabetes Therapy, 11(2), 387-409. https://doi.org/10.1007/s13300-019-00743-7
  • Świątoniowska, N., Sarzyńska, K., Szymańska-Chabowska, A., & Jankowska-Polańska, B. (2019). The role of education in type 2 diabetes treatment. Diabetes research and clinical practice, 151, 237-246. https://doi.org/10.1016/j.diabres.2019.04.004
  • Bradley, M. S., Beigi, R. H., & Shepherd, J. P. (2019). A cost-minimization analysis of treatment options for postmenopausal women with dysuria. American Journal of Obstetrics and Gynecology, 221(5), 505-e1. https://doi.org/10.1016/j.ajog.2019.04.031
  • Kornfält, I. H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2021). Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome. Infectious Diseases, 53(2), 94-101. https://doi.org/10.1080/23744235.2020.1834138