SOAP NOTE ON UTI (2 COPIES ON SAME TOPIC)

SOAP Note Week Eight – Pediatric UTI

Carla J. Aldaz, RN, BSN

United States University

FNP592: Common Illness Across the Lifespan

Professor Gryan Garcia

June 28, 2021

SOAP Note Week Eight – Pediatric UTI

ID: S.U., DOB: 11/16/2007, 14-year-old Caucasian Female present to the clinic with her Mother. The Patient and Mother appear to be reliable historians.

S: CC: “Cloudy, foul-smelling pee, and is burning and painful x 3 days.” HPI: S.U. is a 14-year-old Caucasian Female that presents to the clinic with her Mother. The Mother states that the child has frequently been urinating, and the urine is cloudy and foul- smelling. The child expresses that it is uncomfortable to urinate as it has a burning sensation. The child states that it started 3 days ago after she got home from swim camp. She denies blood in the urine, vaginal discharge, or irritations along with SOB, flank pain, or fever. The patient rates pain 7/10 when urinating.

PMH: Gestational age 40 weeks delivery was vaginal, Met growth and developmental milestones, no phycological or social concerns. The Patient is with optimal physical, social, and mental health. Allergies: No known drug allergies, No food allergies, No seasonal allergies Surgical: Wisdom Teeth 2020 Medication: None Vaccinations: Up to date on childhood vaccines, Flu shot November 2020 Social History: The Patient lives with her Mother: Father, and older brother in a single-level home. The Patient is just completed 8th grade and will be starting her freshman year. The Patient is a single heterosexual that is not sexually active. The Patient babysits 2x a week and plays soccer. Father is a Dentist, and Mother is a Hairstylist. Menstrual cycle started at age 12 and is regular. Her last menstrual period was two weeks ago. The patient eats a well-balanced diet; No guns are in the home, and Patient feels safe.

Family History: Maternal Grandparents-Grandmother-68 Hx: Glaucoma Grandfather-60 diseased- Lung Cancer Paternal Grandparents- Grandmother- 65 No medical history healthy Grandfather-66 Hx: Hypertension, DMII Father- 39 Hx: Hypertension Mother-38 Hx: Hypothyroid Brother- 16 Healthy no medical history

ROS:

Constitution: Denies weakness, fatigue, weight loss, or fever at this time HEENT: Denies dizziness, vision impairment, or headache, Denies hearing loss ear pain or discharge, Denies loss of smell, congestion or sinus pain, Denies sore throat, sores, lesions, or bleeding gums Pulmonary: Denies SOB, dyspnea on exertion, cough, wheezing, and no history of Asthma or seasonal allergies Cardiovascular: Denies Chest pain, palpations, no murmurs, syncope, or swelling Skin: Denies itching, dryness, loss of hair, rashes, or changes in nail texture Gastrointestinal: Denies nausea, vomiting, change in appetite, or bowel

movements Genitourinary: Complaints of frequent urination, burning and 7 out of 10 pain during urination, Report cloudy, foul-smelling urine, Denies blood in the urine or vaginal discharge Musculoskeletal: Denies muscle pain or aches, No joint deformities or issues with gait Neurologic: Denies paresthesia, numbness or tingling Psychiatric: Denies depression or suicidal ideation Hematologic: Denies bruising, bleeding history of anemia or fatigue

Allergy/immunologic: Denies allergies or immunologic compromise

O: Vital Signs: Temp: 98.4 HR: 80 RR:17 BP:117/68 O2: RA 100% Wt: 125 Ht: 63in. BMI:22.1 Pain Scale: 7/10- During urination

Physical Exam: Appearance: Happy pleasant, and cooperative teenage female in no acute distress. Alert and oriented x4. Patient and Mother engaged in conversation; Patient maintains eye contact and answers each interview and examination question. HEENT: Normocephalic Normal hair distribution, No visual or hearing impairment, PERRLA, TM intact and pearly gray, Nasal mucosa pink and moist, oral mucosa pin and moist neck non- tender trachea midline, no lymph node swelling or tenderness, good dentition, no lesions or sores noted. Pulmonary: Lungs symmetric with equal rise and fall clear to auscultation bilaterally, no rales, rhonchi, or wheezing noted Cardiovascular: Regular Heart Rate S1 and S2 upon auscultation, no murmurs, gallops, rubs, heaves, or lifts noted Skin: Natural in color, warm to touch, smooth and dry, good skin turgor, no rashes, lesions, bruising, or cyanosis noted. Abdomen: Nontender, soft, normoactive bowel sound in all 4 quadrants Genital-Urinary: Bladder not distend on palpation, denied vaginal discharge, frequent, painful burning sensation with urination No vaginal exam was performed. Musculoskeletal: Full ROM w/ 5/5 strength bilaterally in upper and lower extremities. No joint or muscle pain or tenderness noted, steady gait Neurological: Motor function intact, no weakness or tremors Psychiatric: Affect and mood stable

A: Differential DDX:

• Urinary Tract Infection N39.0: Patient complains of frequent urination with burning sensation while urinating for 3 days after returning home from swimming camp. The Patient states 7 out of 10 pain during urination. In addition, the Patient reports cloudy, foul-smelling urine, Denies blood in urine, vaginal discharge, or fever.

• Vaginitis N77.1: Patient has painful urination, and foul-smelling odor in urine R/O patient is not sexually active and does not have any vaginal bleeding, itching, or discharge (Dains & Ciofu Bauman, 2020).

• Urethritis N34.1: Patient has painful, frequent urination R/O patient is not sexually active and does not have any vaginal itching, irritation, or discharge (Dains & Ciofu Bauman, 2020).

FINAL DX: Urinary Tract Infection

P: Diagnostic:

U/A: Urine dipstick specimen (Hollier, 2021).

Tested Sample Showed: Urine dipstick specimen yielded a small amount of cloudy urine, positive for leukocyte esterase, and nitrite test.

Pharmacological Treatment: • Current treatment recommendations for UTI therapy for young women without

comorbidities is a short course of 3-7 days of antibiotics (Hollier, 2021). • Sulfamethoxazole/ Trimethoprim (Bactrim) 160mg PO BID for 3 days (Hollier, 2021).

Non-Pharmacologic Treatment Plan:

• Education: Good hydration to prevent further health complications like kidney stones while taking Bactrim (Dains & Ciofu Bauman, 2020).

• Education on medication compliance: Instruct patient to take medication as prescribed and not take extra medication for a missed dose. Avoid exposure to sunlight and tanning beds as Bactrim can cause sensitivity to sunlight (Dains & Ciofu Bauman, 2020).

• Education to avoid hygiene sprays and douches (Dains & Ciofu Bauman, 2020). • Education on proper wiping from front to back(Dains & Ciofu Bauman, 2020). • Education on the importance to not wear wet or tight underwear to reduce risk of

infection/Instruct patient to change out of wet swimming suit after swimming (Dains & Ciofu Bauman, 2020).

• Education on Cranberry juice to help reduce recurrent infections (Dains & Ciofu Bauman, 2020).

Follow-up: 1 week to monitor signs and symptoms instruct patient and Mother to contact office increased signs and symptoms, shortness of breath, nausea, vomiting, diarrhea, dark urine, dizziness, fever or skin reaction.

Reference

Dains, J. E., Ciofu Bauman, L., & P. (2020). Advanced Health Assessment and Clinical Diagnosis

in Primary Care (6th ed.). St. Louis, MO: Elsivier.

Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education

Associates. ISBN-978-1