WEEK 10 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
The SOAP note depicts RG 30-year-old woman with complaints of dysuria and urinary frequency for three days. She describes the pain as intermittent and experiences a burning sensation only during micturition, but she began having flank pain last night. She had UTI three years ago and a hysterectomy five years ago. Abnormal exam findings include mild fever (100.9), lower quadrant tenderness on palpation, and CVA tenderness. The assessment findings are UTI and STD. The purpose of this assignment is to examine the SOAP note and identify additional patient information that should be included and discuss possible conditions.
Subjective Portion
The HPI has described key elements, including the onset of symptoms, duration, characteristics, associated symptoms, measures taken to alleviate symptoms, and severity of pain. However, it should have also included the characteristics of the flank pain, whether it is constant or radiating and if sharp, dull, or gnawing pain. The severity of the flank pain should also be included. The patient’s immunization history (last Influenza, Tdap, and Covid vaccine) should also be included in the subjective part (Podder et al., 2021). Besides, the sexual history should be included with information on sexual preference, the number of partners, and condom use, since this guide in assessing the risk of STIs. In addition, the review of symptoms (ROS) has only pertinent positives and negatives in the general and abdominal assessment. All other body systems should have been included since it helps to identify symptoms that the patient failed to mention in the HPI.
Objective Portion
The objective part includes only vital signs and abdominal exam findings. The portion should include findings from general, cardiovascular, respiratory, and genitourinary exams. This is a focused genital and rectal exam, and thus, it should include findings from the examination of the pubic hair, clitoris, urethral meatus, vaginal introitus, perineum, and anus (Podder et al., 2021). In addition, it should have findings from special exams like the bimanual exam and vaginal speculum.
Assessment
UTI is supported by the positive patient’s symptoms of dysuria characterized by a burning sensation when urinating, urinary frequency, and flank pain. It is also supported by physical exam findings of mild fever, costovertebral angle (CVA) tenderness, and tenderness in the lower quadrants (Holm et al., 2021). STD is supported by physical findings of mild fever and lower quadrant tenderness.
Diagnostic Tests
The pertinent diagnostic tests for this case include urinalysis, urine culture, and a complete blood count. The urinalysis will be used to confirm or rule out UTI. Urine culture is an essential confirmatory test and can help identify the specific bacterial pathogen causing urinary symptoms and antimicrobial susceptibility of the causative bacteria (Holm et al., 2021). The CBC can rule out infection and identify if the patient has a complicated or uncomplicated UTI.
Differential Diagnoses
UTI is an appropriate diagnosis for this patient since she presents with the disease’s classic symptoms like dysuria, flank pain, urinary frequency, and CVA tenderness. Therefore, I would accept the UTI diagnosis. Nevertheless, I would reject STD because it is not specific, and the patient does not have adequate subjective findings to support the diagnosis. The likely conditions for this case are:
Acute Pyelonephritis: This is a bacterial infection in the kidney and renal pelvis caused by microbes ascending from the urinary tract into the kidney tissue. Clinical features include fever, chills, tachycardia, tachypnea, flank pain, CVA tenderness, abdominal discomfort, nausea, vomiting, general malaise, burning, frequency, or urgency of urination, and nocturia (Song et al., 2022). Many patients usually have a history of recent cystitis or treatment for UTI. Acute pyelonephritis is a differential owing to positive findings of burning sensation on urination, urinary frequency, flank pain, chills, fever, CVA tenderness, and a history of UTI.
UTI: UTI in adults presents with dysuria, urinary urgency and frequency, lower abdominal discomfort, a sensation of bladder fullness, low back pain, CVA tenderness, bloody urine, and suprapubic tenderness. Rare symptoms include nausea, vomiting, fever, chills, malaise, and flank pain (Czajkowski et al., 2021). UTI is a differential based on dysuria, urinary frequency, flank pain, CVA tenderness, lower abdominal tenderness, fever, and chills.
Cystitis: This is characterized by bladder inflammation due to irritation or infection by bacteria, fungi, viruses, or parasites. Typical clinical features include dysuria, urinary frequency, urgency, flank pain, lower abdominal pain, bacteriuria, sensation of incomplete bladder emptying, and urine retention (Kulchavenya, 2018). Cystitis is a likely diagnosis based on positive features of dysuria, urinary frequency, chills, fever, and lower abdominal tenderness.
Conclusion
The subjective portion should describe the flank pain and include immunization history, sexual history, and ROS of all systems. Besides, the objective should include general, cardiovascular, respiratory, and genitourinary assessment findings. The appropriate lab tests for this case are urinalysis, urine culture, and CBC to identify if the patient has UTI and identify the causative organism. The differential diagnoses are acute pyelonephritis, UTI, and cystitis.
References
Czajkowski, K., Broś-Konopielko, M., & Teliga-Czajkowska, J. (2021). Urinary tract infection in women. Przeglad Menopauzalny = Menopause Review, 20(1), 40–47. https://doi.org/10.5114/pm.2021.105382
Holm, A., Siersma, V., & Cordoba, G. C. (2021). Diagnosis of urinary tract infection based on symptoms: how are likelihood ratios affected by age? a diagnostic accuracy study. BMJ Open, 11(1), e039871. https://doi.org/10.1136/bmjopen-2020-039871
Kulchavenya, E. (2018). Acute uncomplicated cystitis is antibiotic unavoidable?. Therapeutic Advances in Urology, 10(9), 257–262. https://doi.org/10.1177/1756287218783
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP notes. In StatPearls [Internet]. StatPearls Publishing.
Song, H. K., Shin, D. H., Na, J. U., Han, S. K., Choi, P. C., & Lee, J. H. (2022). Clinical investigation on acute pyelonephritis without pyuria: a retrospective observational study. Journal of Yeungnam Medical Science, 39(1), 39–45. https://doi.org/10.12701/yujm.2021.01207
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