SOAP Note: Maternal Health and Gynecology

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SOAP Note: Maternal Health and Gynecology
25.01.2022
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Subjective Data

Chief Complaint:

The patient states, “I cannot pee in a normal way as I have a burning sensation each time I start, and my urine is reddish and cloudy.” The patient claims that this condition developed two days before the visit.

History of Present Illness:

A. B. is a 43-year-old female who came to the clinic complaining of acute pain in the abdomen, increased frequency of urination, and a burning sensation when urinating. The symptoms started approximately 48 hours ago. The patient denies fever and neurological pains but admits having acute abdominal pain that pulsates periodically. The patient denies any abdomen injury in the past two weeks as a result of falling or being hit by a heavy object. The patient also denies consuming any substance that might cause intoxication.

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Review of Systems:

Integumentary: A. B. denies any skin disease, but the skin of her arms is scratched by her cat.
Neurological: A. B. reports feeling drained because of insomnia. She denies paresthesias, ataxia, or paralysis.
ENT: A. B. claims that she does not have a headache, a sore throat, or any problem with swallowing. She denies having problems with hearing or indistinct speech. The patient admits to having light nasal congestion.
Eyes: A. B. denies problems with vision such as change or loss of vision or double vision.
Cardio: The patient denies chest pain or any kind of pain that irradiates to the extremities or neck.
Respiratory: The patient denies shortness of breath or problematic breathing. She claims that she rarely has a cough.
GI: The patient admits having abdominal pain but denies vomiting, constipation, diarrhea, or nausea.
GU: The patient complains of problems with the urinary tract. The major complaints are itching a persistent need to urinate, inability to urinate, and a burning feeling when urinating.
Musculoskeletal: A. B. denies having muscle or joint pain as well as muscle spasms or back pains. The patient admits feeling overall weakness due to bad sleep.

Allergies:

A. B. has an allergy to Novocaine and peanuts.

Immunizations:

The patient does not practice immunization.

Past Medical History:

The patient has a past medical history of hypertension, pneumonia, and arthritis.

Past Surgical History:

The patient had appendicitis removal surgery 12 years ago.

Family History:

The patient’s father, who is 67 years old, has diabetes and arthritis. Her mother, aged 62, has a history of hypertension and obesity. The patient has no brothers or sisters.

Social History:

A. B. is an African American. She is married and has a 12-years-old son. Due to her religious beliefs, the patient does not consume alcohol or smoke and she refuses vaccination and injections. However, she accepts the possibility of curing the ill body with medicines such as pills. The patient denies using any drugs.

Objective Data

Vital Signs and Other Measurements:

Age Gender Ethnicity Height Weight BMI
43 years Female African American 6’1 145lbs 29.9
Temp HR BP RR O2Sat
100 75 125/75 19 97%

Physical Exam:

General: The patient is friendly and alert.
Neurological: The patient is communicable and well-oriented. The speech tempo is moderate. The reflexes of the patient as well as the muscle tone are normal.
HEENT: The patient’s face and skull are symmetrical. Corneal light reflex and red reflex are positive. The patient has a red sclera with visible vessels. The pinna and auricleare not red. Her tympanic membrane is grey. The color of the nasal mucosa is red. The patient’s tongue is white.
Neck: The trachea is midline, symmetrical, and of a regular size. The lymph nodes are of a regular size and not palpable.
Lungs: RR: 19. O2 sat: 97%. The patient has no shortness of breath. The patient’s breath is deep; no crackles are present.
Cardio: HR: 75. BP: 125/75. V1 and V2 ST segments are normal.
GI: The abdomen is soft; surgical scars after appendicitis surgery were revealed. All abdomen area has bowel sounds. The palpation revealed no masses. During the palpation of the middle abdomen, the patient experienced pain.
GU: The patient complains of dysuria but denies polyuria.
Musculoskeletal: The patient denies lower back pain. The extremities are of moderate strength.
Extremities: The analysis did not approve cyanosis, clubbing, or edema.
Integumentary: The patient’s skin is grey, of slightly elevated temperature; the patient is not sweating.

Diagnostic Exams:

Test Results
Urinalysis Color – Dark yellow

Appearance – Cloudy

Specific Gravity – 1.054

pH – 7.6

Protein – 1+

Glucose-Strip – Negative

Ketones – Negative

Bilirubin – Negative

Occult Blood – Positive

Struvite (MgNH4PO4) Crystals 11-17

Ammonium Urate Crystals >50

Escherichia coli?– Greater than 100,000 cfu/ml

Chlamydia antigen test – Negative

Mycoplasma hominis– Negative

Ureaplasma urealyticum– Negative

Assessment

Final Diagnosis: Acute cystitis (bladder infection).

Differential Diagnoses:

1. Female non-gonorrhea urethritis.

2. Chlamydial genitourinary infection.

3. Bladder cancer.

4. Desquamative inflammatory vaginitis.

Acute cystitis, or bladder infection, is a urinary tract infection (UTI) that typically refers to the condition when bacteria infect the bladder or lower urinary tract. The chief complaints of the patient refer to several conditions related to the problem with bladder that is caused by infection or an oncologic pathology such as bladder cancer. For instance, the reported symptoms such as the frequency and urgency of urination and dysuria coincide with those of acute cystitis (Choi, Kim, & Bae, 2015). At the same time, the signs of blood in urine and abdominal pain may indicate the development of bladder cancer (T?lle et al., 2013).Therefore, there is a need for performing an objective data analysis.

Based on the physical examination, A.B. displays symptoms that allow diagnosing acute cystitis. In particular, the patient reports the change of the color, smell and constituency of her urine, abdominal pain, itching and burning feeling when urinating, and expresses the need to urinate frequently. At the same time, there is a probability of confusing these indicators with other diagnoses such as urethritis, vaginitis, chlamydial genitourinary infection, or bladder cancer. In order to avoid a diagnostic mistake, scholars advise diagnosing urine of a women patient “with symptoms suggestive of cystitis to assist with diagnosis or to determine antimicrobial susceptibility” (Hooton, Roberts, Cox, & Stapleton, 2013, p. 1883). Based on the analysis of the patient’s complaints and symptoms and urine test results, the patient is most likely to have developed acute cystitis, as Escherichia coli was found in urine.

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Although the primary diagnosis for the patient is an acute cystitis, other differential diagnoses should be considered. The four differential diagnoses for the patient are urethritis, vaginitis, chlamydial genitourinary infection, and bladder cancer, which are irrelevant as the visual and urine test did not confirm them. Urinalysis did not reveal the presence of micro RNA in the urine of the patient, which is described as a critical marker of bladder cancer (T?lle et al., 2013). Micro RNA fingerprint is a reliable non-invasive diagnostic tool that allows revealing bladder cancer, which is why the patient does not require an x-ray or any additional screening (T?lle et al., 2013). Similarly, the urinalysis did not reveal the indicator of female non-gonorrhea urethritis, which is why the patient has no female non-gonorrhea urethritis. The reason for this suggestion is that chlamydia antigen test is negative (Hsu et al., 2016). Similarly, Mycoplasma hominis, and Ureaplasma urealyticum tests were also negative, whereas they are most prevalent indicators of urethritis (Hsu et al., 2016). Finally, the patient did not suffer from desquamative inflammatory vaginitis, as itching and a burning feeling along with abdominal pain are not supported by other clinical evidence. Thus, the patient did not complain of having yellowish vaginal discharge, vulvovaginal discomfort, or dyspareunia, which are the most typical symptoms of desquamative inflammatory vaginitis (Mitchell, King, Brillhart, & Goldstein, 2017). At the same time, the performed urinalysis showed the presence of Escherichia coli microbial culture. Experts claim that Escherichia coli are especially associated with the cases of recurrent cystitis in women (Agarwal, Mishra, Srivastava, Srivastava, & Pandey, 2014). This diagnosis is supported by the clinical picture and the chief complaints of the patient, which is why the final diagnosis is an acute cystitis.

Plan

First, the patient should be informed of the clinical diagnosis and provided general education related to issues that provoke the development of acute cystitis. Due to the acute nature of the disease, the patient requires administration of analgesics. The most common analgesics used for alleviating pain caused by urinary tract infections are phenazopyridine and methenamine hippurate (Pergialiotis et al., 2012). Administration of phenazopyridine would stop pain and discomfort of the urinary tract. Furthermore, the patient requires administering antibiotics such as Cefotaxime, Imipenem or Nitrofurantoin, as they demonstrate 99% – 100% efficacy against Escherichia coli (Etienne et al., 2014). Additionally, there is a need for considering the possibility of applying an alternative treatment, which is connected with the risks for health associated with the use of antibiotics. For instance, experts indicate that Escherichia coli may have increased resistance to a wide range of antibiotics, whereas an aggressive antibiotic therapy may eliminate the normal microbiota (Foxman & Buxton, 2013). Thus, an alternative solution is good hydration, frequent voiding, and consumption of Lactobacillus probiotics, which potentially minimizes inflammatory symptoms (Foxman & Buxton, 2013). However, this strategy suits more as a prevention rather than treatment of the cases of acute cystitis, which is why such therapy is irrelevant in the case of A. B. In addition, the patient should be informed about the principles of administration of analgesics and antibiotics, as the failure to follow the prescription is a common problem among patients (Pergialiotis et al., 2012). Finally, the patient should be instructed to follow up in one week after the end of treatment and have laboratory tests completed.

Reflection Notes

The analysis of the complaints, clinical diagnosis, and the condition of A. B. leads to the consideration of specific factors. First, a clinical practitioner should take into account statistical factors that are associated with specific diseases. For instance, urethritis is a disease that is statistically prevalent in men, whereas women may have only female non-gonorrhea urethritis (Hsu et al., 2016). Similarly, women are at a higher risk of developing other UTIs as they void frequently, lack antibody receptors on the urethral mucosa, and have a shorter urethra than men (Jha & Kher, 2016). Therefore, the performance of laboratory tests is critical, as the patient’s condition is caused by the activity of pathologic microorganisms that have a different antibiotic susceptibility. Therefore, in case I face a patient with similar complaints, I will ask him or her to perform laboratory tests. In addition, my mistake was that I failed to perform a blood test, which is required for the support of microRNA fingerprint along with a urine test (T?lle et al., 2013). Therefore, the analysis of the individual experience of diagnosing and treating a patient with acute cystitis demonstrates that the efficacy and relevance of the assessment may be improved in the future.

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