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29-year-old Caucasian female visiting the clinic today on 3rd November 2018 at 14:00hrs.
Chief Complain
“I am visiting today because I have been feeling intense pain in my right lower abdominal region. I have also been experiencing a burning sensation and pain when urinating.”
History of Presenting Illness
The patient reports that she has been experiencing pain in the lower right abdominal region for the past two days, which has been intensifying since then. She explains that the pain complicated to painful urination and increased urgency of urinating that is accompanied by a burning sensation. The woman reports that the pain is aggravated by urination, and it is not relieved by any factors. The patient had tried several doses of over the counter Paracetamol, which did not alleviate the pain. She reports that the pain radiates to the groin region.
Past Medical History
The patient indicates developing Urinary Tract Infections (UTIs) at least three times per year for the past three years. She always seeks medical attention for infections that resolve after medications. She reports no other significant history of past medical conditions. The woman has never been admitted for any illness nor been transfused before.
Past Surgical History
The patient had an appendectomy in 2012. She also had a Caesarian section in 2014.
Social History
The patient is a single mother with one male child aged 4 years. She lives with her son and a nanny in her apartment. The woman is a college graduate nutritionist and works in a nearby hospital. She reports having a negative history of alcohol consumption, substance use, and cigarette smoking. The patient engages in mild physical exercises that involve jogging twice per week. The patient admits to being sexually active but with a single partner with whom they do not use protection. She reports being social and has friendly relationships with her colleagues.
Medications
The patient has been on Paracetamol 1g three times per day for the past two days.
Allergies
The woman reports being allergic to penicillin. She has no known allergies to any food.
Family History
She has both parents who are still alive. Her mother has been suffering from hyperlipidemia for the past four years. Her father was once diagnosed of tuberculosis that was treated and resolved. Her paternal grandfather died of kidney failure. She has two siblings who are well and alive.
Review of Systems
Upon historical review, the patient’s systems exhibited no abnormalities apart from the genitourinary and gynecological systems that had significant data. The patient reports a change in urine color to slight hematuria. She reports intense pain during urination, which is accompanied by a burning sensation and increased urgency. She has a frequent history of UTIs. She denies experiencing abnormal vaginal discharge. She is a para 1+0 and has never experienced dyspareunia or dysmenorrhea.
Objective
Physical Exam
General Appearance
The patient looks healthy and oriented as well as gives appropriate answers to the asked questions. She is in pain 6/10 rated on the pain scale, but she is not in acute distress.
VS/ Ht/ Wt/ O2 Sat
The patient has a weight of 60 kgs, height of 5ft, her temperature is 37.9’ C, BP is 100/79 mmHg, respirations are 22 breaths/min, and HR is 122beats/min. The patient’s oxygen saturation is 97%.
Skin.
The skin’s integrity is maintained. She has a cool moist skin with no pallor.
HEET.
The patient’s head is non-traumatic with well-distributed blonde hair. The woman has equal round brown pupils, 2mm in diameter. Her extra-ocular muscles are intact. The patient’s ears have bilaterally patent ear canals with well-visualized landmarks. Her nose has a moist pink mucosa without lesions or abnormal discharge. Her throat has non-palpable lymph nodes.
Neck.
On palpation, there is no lymphadenopathy of the cervical nodes. The trachea is well situated in the midline.
Cardiovascular.
The S1 and S2 heart sounds are well auscultated. She has no adventitious sounds. Her apical pulse is well pulsated and non-displaced. The patient’s peripheral pulses have a bilateral regular rhythm. Her capillary refills in 2 seconds.
Lungs.
Clear lung sounds auscultated bilaterally. Symmetrical chest rise with absence of labored ventilation
Abdomen.
The patient’s abdomen is soft with presence of bowels sounds in all four quadrants. Moreover, there are no organs palpated in the abdomen.
Genitourinary.
She experiences tenderness in the suprapubic region, flank region, and the costovertebral region. The pain is moderate and unilateral on the right abdominal side. However, on palpation, her bladder is not distended. Vaginal examination was deferred due to the patient’s request based on cultural beliefs.
Neurological.
The patient has an upright posture with well-coordinated movements. She has a good attention and concentration span. Her speech is clear with well-regulated tone and rhythm.
Musculoskeletal.
The woman has a non-tender spinous process. She has a well-coordinated range of motion in every extremity. She exhibits good muscle strength and tone.
Psychiatry.
The woman is well groomed in an official suit and has good tics with well-maintained rapport. She looks slightly anxious but maintains eye contact.
Laboratory Tests.
The tests to be conducted include urinalysis and blood culture.
Imaging.
The imaging test to be conducted is a CT scan.
Other.
None at this time.
Assessment
The diagnosis of the patient based on the clinical presentation is pyelonephritis.
Differential Diagnoses
Cystitis and pelvic inflammatory disease.
Plan
Medication
The patient is prescribed with oral trimethoprim-sulfamethoxazole 160 mg/800 mg tablet twice-daily for two weeks (Center for Disease Control and Prevention (CDC), 2017). Diclofenac sodium 75mg tablets to be taken two times a day for 5 days (CDC, 2017).
Non-drug therapy
The non-drug therapy for the patient include ingesting plenty of fluids.
Labs and Imaging
Lab works include urinalysis and urine culture. The imaging test that should be conducted is a CT scan.
Splints/ Sling
The patient’s condition does not require the use of splints or a sling.
Follow-up
The patient should revisit the clinic after completion of the prescribed medication for review. However, in case of intensified symptoms after the treatment, she is advised to come after 3 days.
Referral
The woman is referred to a nephrologist for intensive review and specialized management.
Education
The patient’s education involves educating her on the importance of adhering to the prescribed medication to the latter. It also comprises enlightening her on the disease process, such as the disease progress and possible complications.
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SOAP Note Analysis
Subjective
Pyelonephritis is a condition that affects the kidneys resulting in various symptoms. Majorly, it presents with pain in the flank or groin region, which is accompanied by urinary urgency, frequency, and dysuria (Johnson & Russo, 2018). Such symptoms compare with the patient’s presentation of acute pain on the lower right abdominal region that was radiating to the groin region, dysuria, and a burning sensation on urination. The patient’s subjective data on the fact that her urine was slightly hematuric compares with the literature on pyelonephritis which causes the urine to either be cloudy due to presence of pus or bloody due to presence of blood (Johnson & Russo, 2018). The woman’s further symptoms of developing chills, body fatigue, nausea, and vomiting clearly depict the diagnosis of pyelonephritis. The studies have shown a positive history of nausea, vomiting, and generalized malaise in patients diagnosed with pyelonephritis (Johnson & Russo, 2018).
The patient’s age and sex relate to pyelonephritis in the essence that the disease is more established in sexually active women. because the reason is that sex precipitates the movement of E. coli bacteria to the urinary tract, which results in the development of a UTI (Johnson & Russo, 2018). Women also have a shorter urethra than men; therefore, the bacteria easily reach the kidneys, hence causing various infections. Frequent UTIs act as a risk factor for pyelonephritis since UTIs catalyze the spread and colonization of bacteria in the kidney, which later develops into serious kidney infections (Johnson & Russo, 2018). The woman’s culture of not being assessed in the vaginal region unless very necessary was respected by the fact that the vaginal examination based on the patient’s request was deferred.
Objective
From the analysis of the patient’s vitals, the patient has a moderate fever of 37.90. Fever is one of the symptoms presented by most patients with pyelonephritis (Johnson & Russo, 2018). The fever denotes that the patient’s immune system has been activated to fight a bacterial micro-organism. On palpation, the physical examination findings depicted tenderness on the costo-vertebral region and the supra-pubic region of the patient’s abdomen. Such findings compare with the literature of pyelonephritis where patients present with a tender costo-vertebral angle with flank pain (Johnson & Russo, 2018). Studies also show that some patients with pyelonephritis experience suprapubic as well as abdominal tenderness (Johnson & Russo, 2018). It was positive with the patient’s physical examination.
The urinalysis and blood culture tests ordered are essential since they are among the best tests that rule in pyelonephritis. The urinalysis test shows presence of leucocytes, microscopic hematuria, and pyuria (Johnson & Russo, 2018). The urine culture test is done in pyelonephritis cases to ascertain the presence of bacteriuria to establish any possibilities of antibiotic resistance (Johnson & Russo, 2018). The CT scan test conducted as an imaging procedure is essential to detect possible urinary tract obstructions that result in pyelonephritis (Johnson & Russo, 2018). The CT scan results also help rule out possibilities of non-renal involvement in the symptoms.
Assessment
The clinical presentation of the patient involving pain in the lower abdominal region, fever, urinary urgency, pain, and burning sensation on urination ruled in three diagnoses. The mentioned symptoms are classical in pyelonephritis, cystitis, and pelvic inflammatory disease (PID) (CDC, 2017). However, the patient’s diagnosis was pyelonephritis and not cystitis, as cystitis does not present with chills or gastrointestinal symptoms of nausea, vomiting, and back pain (Grigoryan, Zoorob, Wang, & Trautner, 2015). The patient’s final diagnosis was neither PID, as in PID, a patient presents with abnormal vaginal discharge (CDC, 2017). The patient in the case had no abnormalities in the vaginal discharge. The woman’s history of frequent UTIs also adds as a positive risk factor to pyelonephritis and not cystitis or PID.
Plan
The patient’s medication regimen was prescribed according to the CDC guidelines. The prescription of trimethoprim-sulfamethoxazole is relevant to this patient’s diagnosis based on her history. The patient’s history of frequent UTIs might depict that the cause of pyelonephritis was susceptible to uropathogen (CDC, 2017). The chosen antibiotic regimen would, therefore, be the best in clearing the infection within the stipulated time. Diclofenac is an effective drug in relieving pain related to urinary tract conditions (CDC, 2017). The pharmacodynamics of trimethoprim-sulfamethoxazole involves bactericidal activity. The drug starves bacterial micro-organism through the inhibition of folate synthesis (CDC, 2017). Such action makes it effective in the treatment of non-complicated pyelonephritis as an efficient plan to relieve the patient’s presenting symptoms. Thus, there are zero chances of drug interactions or implications since the patient is not on other medications.
The monitoring strategy for the patient involves a revisit to the clinic after 72 hours in case the symptoms persist. A therapy with effective empiric antibiotics produces effect after 48-72 hours (CDC, 2017). The patient is recommended to take a lot of water as non-drug therapy to help clear out the bacteria in the kidneys. Patients on antibiotic therapy should have a follow-up plan; thus, she is recommended to revisit after completion of the therapy unless necessary. The patient is also referred to a nephrologist for advanced review. It is important that a patient is acquainted with the course of the disease she is diagnosed with. In this way, a detailed educative session on pyelonephritis was discussed with the patient. Managing this patient has taught me how intensive pyelonephritis is and its pertinent risk factors. From the assessment of the patient’s management, I think the patient has been well managed, and I would barely do anything different. The woman’s cultural consideration of being excluded from vaginal examination unless critically necessary was considered during the plan of care by being deferred as requested.
Summary
All in all, Annalise H. is a 29-year-old female who presented to the clinic with complains of lower abdominal pain that radiates to the back and groin region. The discomfort had presented for two days and was accompanied by urinary urgency and dysuria. The patient also reported to have experienced episodes of chills, nausea, and vomiting. On physical examination, she had right costo-vertebral angle tenderness with suprapubic pain. The woman had a mild fever of 39.70C and tachycardia. Urinalysis, urine culture, and CT scan were the major diagnostics conducted. The patient was started on trimethoprim-sulfamethoxazole and diclofenac. She is required for follow-up after completing medication, and she has been referred to a nephrologist.