I Need two Responses Per Each Discussion(soap note) Total 6 Responses. Attached Are The Discussions(soap Note) .One Reference Per Each Discussion

Subjective:

 

Chief Complaint: "I’m having Burning urination and flank pain".

 

History of present illness (HPI): 32 y/ female, hispanic race; came to follow-up UTI, she had treatment with Bactrim due culture and sensitivity positive to E. Coli, but she continue with intermittent pain in left flank, accompanied with nausea, and lot effort to start pee, poor relief with Tylenol 650 mg PRN for pain, no fever, renal US done and show image of lithiasis (2mm) left distal ureter, and another one in the left renal pelvis(4mm), new prescription given, and referral to urologist.

Past Medical History (PMH): UTI.

 

OHx: G0P0A0, 1 vaginal delivery, 1 spontaneous abortion. Allergy: NKA.

Vaccine schedule is update. Hospitalization due to UTI.

Family History (FH): Father HTN and Mother DM and HTN.

 

Social History (SH): married, never smoker, drug no, alcohol no, she works in the office. Surgery: None.

Actual medications: Tylenol 650 mg PRN for pain. ROS:

Constitutional: no fever, no change weight reported. Normal gait.

 

Neurologic: no headache, no vertigo, no paresthesias, no motor deficit, and denies loss of conscience.

HEENT: No head injury recorded denies any changes in vision, denies loss of hearing, no report hoarseness, no swallow difficulty, he denies throat pain or swallow neck.

Respiratory: No shortness of breath, no dyspnea, no pain.

 

Cardiovascular: No chest pain, palpitation and fatigue during the exercise or at rest. Gastrointestinal: Nausea, No abdominal pain, diarrhea and constipation.

Musculoskeletal: no motor deficit, no fall, left flank pain.

 

Genitourinary: pain in the left flank (3/10), accompanied with nausea, and lot effort to start pee, poor relief with Tylenol 650 mg PRN for pain, no fever.

Skin: No alterations.

 

Objective Data:

 

Constitutional:

 

Vital Signs:

 

Temp: 98.5 F

 

B/P: 120/80 mmHg Pulse: 88X'

RR: 16 X'

 

Weight: 168 p.

 

Height: 5’.6''

 

BMI 24.5 m2.

 

HEENT: Ear canal normal, no discharge or pain noted, tympanic membrane normal in appearance, movable and bony landmarks visible, no masses palpable in the neck, thyroid no palpable, No jugular veins distention.

Cardiovascular: normal nail beds, no edema in lower extremities, capillary refill time is less than 3 seconds, no calf tenderness noted, and radial, pedal, and apical pulse present and regular rhythm, S1 and S2 normal auscultation, no murmurs or rubs.

Respiratory: unlabored respiration, Vesicular breath sound normal.

 Gastrointestinal: abdomen flat and soft, non- distended, left flank pain 5/10, Bowel sounds present in 4 quadrants, Murphy's sign, Blumberg's sign negative.

Musculoskeletal: normal gait, normal strength in lower upper extremities, no joints swelling, normal lower back muscles tenderness 3/10 pain scale, superficial and deep reflex normal, and no deformities noted.

Genitourinary: CVA tender points, no cystocele, no rectum prolapsed, clean vagina, Speculum Examination shows the cervix without nodules or changes in color, vagina is free of lesions. Rectal Examination: there are no lesions on palpation, no masses.

Integumentary: skin warm and wet, intact, moist mucosa, no jaundice, no purpura manifestation, good turgor, normal texture, and implantation of the hair according to age.

Neurologic: normal gait examination, alert and oriented x 3, no speech problem, assessment of the XII cranial pair was negative, no sign of Kernig, and Brudzinski, strength in all extremities is normal, all reflex is normal, PERRLA, Glasgow coma scale 15 points.

Assessment:

 

ICD 10: N10; Pyelonephritis: The classic manifestations of acute pyelonephritis observed in adults are often absent in children, particularly neonates and infants. In children aged 2 years or younger, the most common signs and symptoms of urinary tract infection (UTI) are as follows: Failure to thrive, Feeding difficulty, Fever, Vomiting.

Differential Diagnostic

 

ICD 10: N 20.9; Calculus of kidney with calculus of ureter, Stones due to infection (struvite) are more common in women. An untreated staghorn (branched shaped) with persistent renal obstruction can destroy renal tissue with potential for life-threatening sepsis

ICD 10: I71.00; Dissection of an aortic aneurysm: Symptoms vary according to the size, location, and changes in the aneurysm. Chest, back, and abdominal pain are common symptoms in patients who are symptomatic. Note the following: Aortic root dilatation may lead to

symptoms of congestive heart failure (CHF) due to aortic insufficiency. Hoarseness may signify vagus or recurrent laryngeal nerve compression.

ICD 10: K85.90; Acute pancreatitis: is inflammation of the pancreas. It occurs suddenly and causes pain in the upper abdominal (or epigastric) region. The pain often radiates to your back.

Plan of Care:

 

Pharmacologic treatment

 

Ketorolac 10 mg PO Q6hrs for 5 days. Metoclopramide 10 mg PO Q8hrs.

Laboratory Exams:

 

CBC BMP

Urinalysis with C/S Renal and pelvic US.

Non-Pharmacologic treatment Increase fluids to allow passage of stone. Strain all urine to recover stone for analysis. Consider dietary consultation after stone analysis. Take your treatment as the doctor suggested, you need to drink plenty of fluids in the next 3 days, avoid being

constipated, eat foods rich in fiber, fruits and vegetables, it is recommended to avoid salts or condiments.

Be sure to observe each time you urinate if you have small traces of calcifications.

Take warm baths several times a day, they can help calm your state of anxiety about pain. Avoid bedding, walk, and wear baggy clothes, avoid extreme temperatures, cold or hot.

Referral (s): not at this time. F/U: 1 week.

References:

 

1. "Chapter 135: Approach to the Paient with Nephrolithiasis". In Goroll AH, Mulley AG (eds.). Primarycare medicine: office evaluation and management of the adult patient (6th ed.).Philadelphia: Lippincott Williams & Wilkins. pp. 962–7.

2. "Medical management of common urinary calculi" (PDF). AmericanFamily Physician. 74 (1): 86–94.

3. "Ch. 37: Nephrolithiasis". In Brenner BM (ed.). Brenner and Rector's the Kidney. 1 (8th ed.). Philadelphia: WBSaunders. pp. 1299