soap note 8

Name: P.A.

Date: 04/08/2020

Time: 11:00 am

Age: 26 y/o

Sex: F

SUBJECTIVE

CC: 

” I have some slight pain and discomfort in my lower belly nearer to my groin area”

HPI: P.A. is a 26-year-old Hispanic female that came to the office today complaining of pain in her lower abdomen. The patient states that the pain began around 2 days ago. It is located on her right and left lower abdomen around her pelvic region. It has lasted all day long for the past two days as a slight discomfort and some slight pain described as a 3 on a scale of 10. It is a dull pain. The patient has tried using over the counter Tylenol, but it does not work. The patient states that nothing she does including standing, sitting, or laying down relieve the pain. The patient also states that she has frequent urination. She even states waking up in the night to go pee, something that she has never done in the past. She also states that she has pain on urination described as a burning pain that does not go away until she stops peeing. The color of the urine is the same as it normally is, a pale-yellow color. Denies fever, vomiting, or chills.

Medications:

2 Tylenol as needed for her pain.

PMH (include-immunization status including Gardisil, GTPLA).

Current or past illnesses: No current or past illnesses

Immunizations: All vaccines updated including flu vaccine and Gardasil.

Allergies: NKA

Medication Intolerances: None.

Chronic Illnesses/Major traumas: None.

Hospitalizations/Surgeries (include delivery of pregnancies here)

No hospitalizations.

G0P0

Family History

Mother: 51 years old, no significant health problems

Maternal Side: No significant health problems

Father: Deceased at 48-year-old, MVA.

Paternal Side: no significant health problems

Social History

Patient is a bartender at a local bar. Her highest level of education is high school. She is single. Does not smoke tobacco products or electronic cigarettes. Does not use any recreational drugs. Drinks alcohol socially. She is sexually active with other females and has been having 1 new partner every 2 to 3 months for the last year. Exercises 4-5 times weekly and keeps a healthy diet.

ROS (Focused)

General Patient denies fever or chills, no weight changes.

Cardiovascular Denies chest pain. Denies palpitations, dyspnea, or orthopnea. 

Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.

Gastrointestinal Denies nausea or vomiting. Denies hemorrhoids, constipation, or diarrhea.

Genitourinary/Gynecological Menarche 13 years old. Regular menstrual periods every 30 days. LMP: 03/23/2020, regular flow. No history of pap smear due to fear of discrimination for sexual orientation. No history of STDs. Positive for lower abdominal pain. Positive for increased urination. Positive for pain on urination.

Breast: Denies alteration of nipples, or discharge. Denies skin retractions. Denies breast pain or changes. Denies lumps.

OBJECTIVE - (if you are seeing a patient for an Episodic OV – PE should relate to the CC)

Weight: 147 lb.        BMI: 22.3

Temp: 98.7

BP: 116/68

Height: 5’8’’

Pulse: 76

Resp: 15

General Appearance: Patient is alert and oriented x 4. Well-developed and nourished. She speaks clearly and appropriate. Good personal hygiene.

Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, no gallops. No thrill or palpable murmurs on palpation. No edema.

Respiratory: Lungs clear to auscultation bilaterally anteriorly and posteriorly, good respiratory effort. No rales, no rhonchi, no wheezes upon auscultation.

Gastrointestinal: Soft, suprapubic tenderness present on palpation. No masses, Bowel sounds presents in all four quadrants. No ascites. No splenomegaly, no hepatomegaly. No rebound, no guarding.

Genitourinary: No CVA tenderness. Suprapubic tenderness on palpation. Genitalia: External genitalia, skin color is consistent with general pigmentation. No vulvar lesions or masses noted. Bimanual examination: Mobile cervix, not painful. Adnexal tenderness is present. Vaginal walls are smooth and pink; no lesions noted. Ovaries are non-palpable. No uterine masses or enlargement.

Lab Tests (list the results if you have them)

Urine Dipstick – presence of leukocyte esterase (LE)

Urinalysis w/culture (pending results)

STD screening – Chlamydia, Gonorrhea, HIV (pending results)

Special Tests (done or ordered during the OV)

None

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis:

1-Acute cystitis without hematuria (N30.00). Patient has the classic symptoms of a lower urinary tract infection including pain in the pelvic area, burning urination, and frequent urination (Cystitis - acute: MedlinePlus Medical Encyclopedia, n.d.). Additionally, the patient is at a higher risk of infection due to many new partners every month with female to female sexual intercourse.

Differential Diagnoses:

1- Chlamydial cystitis and urethritis (A56.01). The patient reports some symptoms associated with chlamydia including painful urination. The patient also had adnexal tenderness found in the bimanual examination that is characteristic of chlamydia (STD Facts – Chlamydia, n.d.). The patient also has new partners every month which increases her risk of getting an STI.

2- Gonococcal cystitis and urethritis, unspecified (A54.01): The patient burning urination which can be a symptom of gonorrhea (STD Facts – Gonorrhea, n.d.). She also has adnexal tenderness which is also characteristic of gonorrhea. Additionally, she is at a higher risk of getting an STI due to new partners every month.

3- Female pelvic inflammatory disease, unspecified (A56.11): According to the CDC, the risk of getting PID increases if you have more than one sex partner, and if your sex partner has other sex partners (Pelvic Inflammatory Disease - CDC Fact Sheet, n.d.). The patient has many sex partners in one year and is at an increased risk for PID. It is characterized by abdominal pain, and burning sensation while urinating, which the patient reports.

Plan/Therapeutics (explain fully)

Plan: 

Pharmacologic: Nitrofurantoin 100 mg twice a day for 5 days.

Non-pharmacological.

-Use hot compresses twice a day for 1 hour each time to alleviate the pain

If the pain worsens come back to the office or go to the nearest ER.

Follow up with patient in one week to review lab results for STI, as well as urinalysis and to perform a complete physical exam.

Conduct pap smear after symptoms resolves.

Referrals:

None

Education:

The patient is advised to start antibiotic treatment with Nitrofurantoin 100mg twice a day for 5 days. She should begin feeling relief in a few days. She should return in one week to review the lab results for STI infections since she is at risk. Educate patient that having more than one sexual partner increase her risk of STDs. Conduct safe sexual practices including washing before and after sex. Come back in one week to conduct pap smear. Although the patient has sexual relations with members of the same sex, it does not mean she is less likely to contract an STI. Do not have any sex until symptoms are resolved. Continue exercises and healthy diet. Drink plenty of water daily (2 liters per day).

References

Cystitis - acute: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved April 11, 2020, from https://medlineplus.gov/ency/article/000526.htm

Pelvic Inflammatory Disease - CDC Fact Sheet. (n.d.). Retrieved April 11, 2020, from https://www.cdc.gov/std/pid/stdfact-pid.htm

STD Facts - Chlamydia. (n.d.). Retrieved April 11, 2020, from https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm

STD Facts - Gonorrhea. (n.d.). Retrieved April 11, 2020, from https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm

 Evaluation of patient encounter:

I agreed with my preceptor that this patient has acute cystitis. She has the classic symptoms and was positive on the urine dipstick. I also think that STI’s cannot be discounted due to her social history.