burning on urination

 

SOAP note on a 20 year old female that presents to clinic for burning while urinating x 1 week
Sample soap note from the professor is below,

SUBJECTIVE DATA (S)

Source of History: Patient is the source of the history; appears reliable.

Chief complaint (C/C)
“I have pain in my lower abdomen and my urine looks pink.”

History of present illness (HPI)
Patient a 47-year-old Asian male, presents to the medical office complaining of lower mid abdominal pain and blood in the urine for 2 days. He stated that 4 days ago the pain started in the left flank and 2 days later it shifted to the lower mid abdomen. He described the pain as intermittent, sharp, and stabbing which lasts approximately about 10 minutes. He rated the pain as 8/10 on a scale of 0 to 10. The pain is aggravated by moving and repositioning; Took Motrin 400mg PO Q6h PRN, bought over the counter without relief. Denies frequency of micturition, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of urinary stream, hesitancy, dribbling, incontinence, urinary infections, stone; hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted infections. Heterosexual, single, in a satisfying monogamous relationship with girlfriend of 4 years. Denies trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching or passing of gas, constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 daily soft brown stool.
Past History
Childhood Illnesses: Denies chickenpox, measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.

Adult Illnesses: Hypertriglyceridemia at age 46 (Patient is currently trying diet, exercise, and fish oil to lower triglycerides).

Psychiatric illnesses: Denies past or present psychiatric illnesses.

Accident and injuries: Denies accidents or injuries.

Operations: Denies history of operations.

Hospitalizations: Denies Past hospitalizations.

Current medications:
– Multivitamin 1 tablet PO daily.
– Omega-3 fish oil 1 capsule PO daily.

Allergies:
– No known drug or food allergies.
– Allergic to dogs and cats (Reaction: itchy eyes and runny nose).

Social history
Tobacco: Denies past or present tobacco use.
Alcohol: Drinks 3-5 12 oz. cans of beer weekly.
Drugs: Denies past or present illicit drug use.
Sexual history: Heterosexual. Monogamous relationship with his girlfriend. He stated that he uses condoms.
Marital status: Single. Good and satisfying relationship with his girlfriend for 4 years; no children by history.
Living situation: Lives by himself in a studio apartment.
Work: Electronic store manager.
Education: Bachelor’s degree- electrical engineer.
Screening tests
– PPD: Negative (05/2016).
– Chest x-ray: Unremarkable (05/2016).
– PSA: 2.4 ng/mg-within normal range (05/2016).
– Hemoglobin A1c: 5.0 -within normal range (05/2016).
– Lipid panel: Within normal limits except triglycerides 170 mg/dl).
– Endoscopy: Unremarkable (2012)
– Colonoscopy: Unremarkable (2012).
– Dental exam: Within normal limits- no cavities or decay (09/2016).
– Eye exam: Vision 20/20 both eyes (07/2015).both eyes)

Immunization
– Influenza vaccine: 10/2016
– Td booster vaccine: 2013
– Patient stated he is up-to-date with his immunizations.

Family history
Maternal grandmother: Medical history unknown. Deceased (age unknown).
Maternal grandfather: Medical history unknown. Deceased (age unknown).
Paternal grandmother: Medical history unknown. Deceased (age unknown).
Paternal grandfather: Medical history unknown. Deceased (age unknown).
Mother: Osteoporosis. Age 76. Living.
Father: Hypertension and hyperlipidemia. Age 80. Living.
No siblings.
No children.
Review of Systems

General: Denies fever, chills, body aches, fatigue, night sweats; changes in weight or sleeping pattern.

Skin: Denies rash, lesions, nodules, lumps, pruritus, dry skin, color change; hair loss or changes in hair texture; changes in shape, color, or brittle nails.

Head: Denies headache, head injury, dizziness, lightheadedness.

Eyes: Patient stated that he has good vision and has never worn glasses or contact lens. Last eye exam more than 2 years, 20/20 vision. Denies eye pain, redness, discharge, recent changes in vision, double vision, blurred vision, blind spots, flashing lights, floaters, glaucoma, or cataracts.
Ears: Denies hearing problem, tinnitus, vertigo, earaches, infection, or discharge.

Nose and sinuses: Denies frequent colds; nasal stuffiness, discharge, itching, hay fever, nosebleeds, change in sense of smell, or sinus trouble.

Mouth and throat: Patient stated that his teeth are in good condition, without staining, or cavities. Last dental visit for cleaning x 3 months ago; has follow up in 3 months. Denies bleeding gums, lesion in mouth or tongue, altered taste, dysphagia, sore throats, hoarseness.

Neck: Denies lumps, “swollen glands”, or goiter, pain or stiffness in the neck.
Breasts: Denies lumps, pain, discomfort, nipple discharge; does not do self-breast examination by history.

Respiratory: Denies cough, hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Last PPD 5/2016 with negative result.

Cardiac: History of hypertriglyceridemia since age 46. Denies history of hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Last EKG done in 2016 (normal result).

Gastrointestinal: Admits to lower mid abdominal pain for 2 days. Pain scale 8/10. The pain is aggravated by moving and repositioning; Took Motrin 400mg PO Q6h PRN, bought over the counter without relief Denies trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching or passing of gas, constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 daily soft brown stool.

Urinary: Admits to hematuria for 2 days. History of left side flank pain 4 days ago. Denies frequency, urgency, nocturia, dysuria, polyuria, oliguria, urinary infections, kidney stones, or incontinence.

Genital: Reports to performing self-testicular exam once a month. Denies hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted infections (trichomonas, chlamydia, gonorrhea, syphilis, hepatitis B or C, HIV, etc.). Heterosexual, single, in a satisfying monogamous relationship with girlfriend of 4 years

Peripheral vascular: Denies intermittent claudication, leg cramps, varicose veins, past clots in the veins, edema, or change in fingertips or toes during cold weather.

Musculoskeletal: History of left side flank pain 4 days ago. Denies muscle or joint pain in the neck, upper extremities, back, lower extremities, swelling, stiffness, arthritis, gout, backache, limitation in range of motion, etc.

Neurologic: Denies changes in mood, attention, or speech; changes in orientation, memory, insight, or judgement; headache, dizziness, vertigo, fainting, blackouts, weakness, paralysis, numbness or loss of sensation, seizures, tingling, “or pins and needles” tremors or other involuntary movements.

Hematologic: Denies anemia, easy bruising or bleeding, lymph node swelling, family history of hemophilia, or history of blood transfusion.

Endocrine: Denies “thyroid trouble”, heat or cold intolerance, excessive sweating, excessive thirst, or hunger, polyuria, polyphagia, change in glove or shoe size.

Psychiatric: Denies nervousness, tension, mood including sadness, hopelessness/helplessness, depression, memory change, hallucinations, suicide ideations or attempts, etc.

OBJECTIVE DATA (O)

General survey: Patient appears well-developed, well-nourished, and well-groomed. Facial grimace and abdominal guarding.

Vital signs: T 98.6 ºF, P 95, RR 18, BP 130/96 (right arm, sitting, automatic), 128/95 (right arm, standing, automatic), oxygen saturation 98% room air, height 6 ft. 2 in., weight 198 lbs. BMI 25.4

Skin: Warm and moist with normal turgor. No rash, lesions, ulcers or unusual bruising. Hair: short and black with wavy texture; equal distribution and without hair loss. Nails: pink with capillary refill < 3 sec. No clubbing.

Head: Normocephalic/atraumatic. Fine hair texture, evenly distributed; scalp clean without lesions, tenderness, or lump; right and left side of the face – symmetrical.

Eyes: Vision 20/20 in both eyes. Conjunctiva pink. Sclera white. Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Visual fields full by confrontation. Disc margins sharp without arteriolar narrowing, AV nicking, hemorrhage, exudates, cotton wool spots, or papilledema.

Ear: No lesions or edema of external ears, manipulation of the pinna without tenderness. Ear canals clear, no cerumen observed; and tympanic membrane pearly grey with good cone of light bilaterally. Acuity good to whispered voice. Rinne test AC > BC. Weber –midline (normally the sound is heard in the midline or equally in both ears (If nothing is heard, try again, pressing the tuning fork firmly because patient with normal hearing may lateralize. Therefore, this test should be restricted with to those with hearing loss).

Nose and Sinuses: Mucosa pink, Nares patent, without discharge.Nasal septum intact, midline without erythema. Turbinates pink and non- enlarge. Frontal and maxillary sinuses non tender on palpation.

Mouth and throat: Oral mucosa pink and moist without lesions. Teeth intact without cavities. Gum pink without swelling, redness, bleeding, or lesions. Tongue intact and midline. Uvula midline. Tonsils present, no exudates, swelling, or redness. Pharynx without erythema or exudates.

Neck: Supple. Trachea midline. No increase pulsation or lymphadenopathy. Cervical lymph nodes non enlarge Thyroid non-palpable.

Back: Spine without deformities, ecchymosis, swelling, or tenderness. No CVA tenderness. Full range of motion.

Anterior/Posterior thorax and lungs: Symmetrical, no deformity, no retraction, equal bilateral chest expansion. Respiratory rate 18 cycles per minute. No tenderness on palpation of the anterior and posterior chest. Percussion notes: Resonant; relative intensity – loud; relative pitch – low; relative duration – long. Vesicular breath sounds auscultated over most of the lungs (anterior and posterior chest). No crackles, rhonchi, or wheezing.
Breast, axillae, and epitrochlear nodes: Symmetrical bilaterally, nipples everted, no thickening of the nipples, no mass, tenderness, or discharge; axillary and epitrochlear nodes non palpable.
Cardiovascular system: No increase carotid pulsation on inspection; palpation of the carotid pulses WNL; no carotid carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; JVP-6 CM H2O. PMI auscultated in the 5th left intercostal space (LICS) in the midclavicular line. Heart sound one (S1) and heart sound two (S2) – normal; regular rate and rhythm WNL. No murmurs, S3, S4, rubs, heaves, or gallops.

Abdomen: Protuberant, no scars (if scars present describe location and measurement). Bowel sounds active in all four quadrants; abdominal guarding, Percussion note tympanic in all four quadrants (except the suprapubic area; unable to percuss due to tenderness). Moderate to severe tenderness on light and deep palpation in the suprapubic area; other areas of the abdomen nontender. Liver and spleen palpable and nontender. Kidneys non-palpable.
Genital: Patient declined.

Rectal: Patient declined.

Peripheral vascular system: Brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis pulses brisk (2+) bilaterally. No rashes, swelling, cyanosis, color change, temperature change, shiny skin, or varicose veins in legs.

Musculoskeletal: Full range of motion of the neck and upper extremities; back and lower extremities. Muscle tone and strength 5/5 bilaterally. Normal gait and station. No deformities, crepitation, tenderness, masses, effusion, or atrophy.

Neurologic system: Oriented to person, place, and time. Thought coherent. Cranial nerve 2 – 12 intact. Rapid alternating movements and point-to-point movements intact. Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg test negative. Biceps, triceps, brachioradialis, patellar, Achilles, and plantar reflexes brisk (2+) bilaterally.

ASSESSMENT (A)

Diagnosis: Nephrolithiasis

Differential diagnoses:
– Nephrolithiasis
– Pyelonephritis
– Acute glomerulonephritis
– Urinary tract infection
– Renal cell carcinoma
– Abdominal aortic aneurysm
– Appendicitis
– Biliary colic
– Diverticulitis
– Colitis
– Epididymitis
– Prostatitis
– Musculoskeletal inflammation or spam

PLAN (P)

A. Diagnostic:
(1) Urine dipstick performed at the clinic (Results: Blood positive, pH 7.8, specific gravity 1.021, protein negative, ketone negative, leukocyte esterase negative, nitrite negative, glucose negative, bilirubin negative, urobilinogen negative).
(2) Urine sample sent to the lab for urinalysis (check for presence of crystals).
(3) Renal & bladder ultrasound STAT order sent to the nearby imaging center.

B. Medication management:
– Percocet 5 mg/325 mg one tablet PO every 6 hours for 5 days as needed for pain.

C. Referral: Will refer to an urologist or send the patient to the ER depending on the ultrasound result and the severity of pain.

D. Patient/family education (including follow-up):
Discussed:

(1) Diagnosis: Informed patient that he has nephrolithiasis or kidney stone, a condition in which one or more stones is present in the urinary tract system.

(2) Some of the signs and symptoms of nephrolithiasis include flank pain, pain that spreads to the lower abdomen and groin, pain while urinating, pink/red/brown urine, nausea, vomiting, and fever/chills if an infection is present.

(3) Importance of having renal and bladder ultrasound done as soon as possible at the nearby imaging center.

(4) Will be called as soon as the ultrasound result is available.

(5) Increase oral fluid intake by drinking 8 -10 (8 ounce) glass of water daily. This may help flush out the kidney stone and also prevent constipation while on Percocet.

(6) Small kidney stones may pass out on its own in the urine; however, larger ones may require procedures such as shock wave lithotripsy to break them into smaller pieces, ureterostomy, or percutaneous nephrolithotomy to surgically remove kidney stones.

(7) Pain can move downward as the stone travels downward in the urinary tract system.

(8) Take Percocet 5 mg/325 mg every 6 hours as ordered.

(9) Percocet contains acetaminophen. Avoid drinking alcohol while taking Percocet as alcohol may increase the risk of liver damage while taking acetaminophen.

(10) Percocet can cause drowsiness. Do not drive or operate heavy machinery.

(11) Call PCP, EMS by dialing 911, or go to the nearest emergency room (ER) if symptoms remain the same or worsen.

(12) Patient verbalized knowledge and understanding of information given.

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