Soap Note Topic : Pyelonephritis Turn it in Score must be less than 20% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 20%. Copy paste from websites or textbooks will not be accepted or tolerated. Please use one of the templates provided to format your soap note. do not use the same data and information ,,just follow template for preparation.
SOAP Note
Subjective:
The patient, a 35-year-old female, presents with complaints of fever, flank pain, and frequent urination for the past three days. She reports a history of recurrent urinary tract infections (UTIs). She denies any hematuria, dysuria, or urgency. The patient states she has been feeling fatigued and has had no appetite. She denies any recent trauma or injury. She reports taking over-the-counter pain medications. The patient has not sought medical attention for her symptoms before today.
Objective:
Vital signs: Temperature 101°F, blood pressure 120/80 mmHg, heart rate 85 bpm, respiratory rate 16 bpm
Physical examination:
General: The patient appears ill and fatigued.
Skin: No rashes or lesions noted.
Head: Normocephalic, atraumatic.
Eyes: Pupils equal, round, and reactive to light. Conjunctiva pink and moist. Sclera white.
Ears, Nose, Throat: Tympanic membranes intact and pearly gray. No nasal discharge or pharyngeal erythema observed.
Neck: Supple, no lymphadenopathy or thyromegaly.
Chest/Lungs: Clear to auscultation bilaterally. No cough or wheezes.
Heart: Regular rate and rhythm, no murmurs or extra heart sounds. No jugular venous distension.
Abdomen: Soft, non-distended, and non-tender. No hepatosplenomegaly. Negative Murphy’s sign.
Genitourinary: No costovertebral angle tenderness. Mild suprapubic tenderness.
Extremities: No edema or clubbing. Pulses are equal and symmetric.
Assessment:
Based on the patient’s clinical presentation and history, the most likely diagnosis is pyelonephritis. Pyelonephritis is a bacterial infection of the kidneys that typically arises as an ascending infection from the lower urinary tract. The patient’s symptoms of fever, flank pain, frequent urination, fatigue, and lack of appetite are consistent with this diagnosis. Her history of recurrent UTIs further supports the suspicion of pyelonephritis.
Plan:
1. Laboratory tests:
– Complete blood count (CBC) to assess for leukocytosis and left shift, which are indicative of infection.
– Urinalysis with microscopy to detect pyuria and bacteriuria.
– Blood cultures to identify the causative organism.
2. Imaging:
– Renal ultrasound to evaluate for any structural abnormalities or complications such as abscess formation.
3. Treatment:
– Empiric antibiotic therapy is indicated for the treatment of pyelonephritis. An appropriate choice would be a fluoroquinolone or third-generation cephalosporin. However, it is important to adjust the antibiotic regimen based on the culture results and susceptibility testing.
– Adequate hydration is essential to promote urinary flow and flush out bacteria. Encourage the patient to increase fluid intake.
– Symptomatic relief can be achieved with analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for pain and fever.
– Patient education regarding the importance of completing the full course of antibiotics and the need for follow-up after treatment.
4. Prevention:
– Encourage the patient to maintain good hygiene practices, including regular showering and wiping from front to back after toileting, to prevent the spread of bacteria from the perineum to the urinary tract.
– Advise the patient to avoid irritants such as bubble baths, spermicidal creams, and harsh soaps that can increase the risk of UTIs.
– Stress the importance of emptying the bladder completely to minimize bacterial growth.
5. Follow-up:
– Schedule a follow-up visit in one week to monitor the patient’s response to treatment and ensure resolution of symptoms.
– If the patient’s symptoms worsen or fail to improve within 48-72 hours, consider hospitalization for intravenous antibiotic therapy.
Summary:
The patient’s clinical presentation and history strongly suggest pyelonephritis. Prompt initiation of appropriate antibiotic therapy, supportive measures, and patient education are crucial in the management of this condition. Close monitoring and follow-up are necessary to ensure resolution of symptoms and prevent complications.