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WEEK 10 I HUMAN DYSURIA AND URINARY FREQUENT: RG is a 30-year-old female GENITALIA ASSESSMENT Subjective: CC: dysuria and urinary frequency$20.49
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WEEK 10 I HUMAN DYSURIA AND URINARY FREQUENT: RG is a 30-year-old female GENITALIA ASSESSMENT Subjective: CC: dysuria and urinary frequency
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Course
I HUMAN DYSURIA AND URINARY FREQUENT
Institution
I HUMAN DYSURIA AND URINARY FREQUENT
WEEK 10 I HUMAN DYSURIA AND URINARY FREQUENT: RG is a 30-year-old female GENITALIA ASSESSMENT Subjective: CC: dysuria and urinary frequency
• HPI: RG is a 30-year-old female with increase urinary frequency and dysuria that
began 3 days ago.
WEEK 10 I HUMAN DYSURIA
AND URINARY FREQUENT :
RG is a 30-year-old female
GENITALIA ASSESSMENT Subjective:
• CC: dysuria and urinary frequency
• HPI: RG is a 30-year-old female with increase urinary frequency and dysuria that
began 3 days ago. Pain is intermittent and described a burning only in urination, but
c/o flank pain since last night. Reports intermittent chills and fever. Used Tylenol for
pain with no relief. She rates her pain 6/10 on urination. Reports a similar episode 3
years ago.
• PMH: UTI 3 years ago
• PSHx: Hysterectomy at 25 years
• Medication: Tylenol 1000 mg PO every 6 hours for pain
• FHx: Mother breast cancer ( alive) Father hypertension (alive)
• Social: Single, no tobacco , works as a bartender, positive for ETOH
• Allergies: PCN and Sulfa
• LMP: N/A
Review of Symptoms:
• General: Denies weight change, positive for sleeping difÏculty because e the flank
pain. Feels warm.
• Abdominal: Denies nausea and vomiting. No appetite Objective:
• UTI
• STD
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be
required for future courses.
, Soap Note Analysis
When examining the SOAP note there are a few things what should be included in the
assessment. When looking at the subjective data, knowing the characteristics of the patient’s
urine would be helpful. Since the patient at a history of urinary tract infections and other urinary
symptoms knowing the color, odor, amount of red blood cells presents, etc.,. Other subjective
data that would be helpful include vaginal discharge and pain during intercourse. This
information would be helpful to rule out possible sexually transmitted diseases.
Objective data that was not included on the SOAP note were some diagnostic tests. There
should have been a point of care for blood sugar done on this patient. Doing a point of care
glucose could also for a rule out of diabetes. Diabetes can cause frequent urinations along with
high blood sugar levels can predispose patients to recurrent urinary tract infections. Other lab
work, I would have sent out would include a CBC, CMP, C-reactive protein, procalcitonin and
urine cultures. These tests should have been ordered to rule out for signs of infections or
presence of microorganisms in the urine. Kidney, uterus, and bladder ultrasound could have been
ordered to check or any masses.
The SOAP notes assessment included urinary tract infection and sexually transmitted
disease. The information provided can indicate the possibility of a urinary tract infection or
sexually transmitted disease, the subjective data gathered is enough to determine these diagnoses.
The objective data ordered was urine specimen and STD testing. The results would have
determined which diagnosis was correct, but more testing should have been done to rule out
bladder cancer or diabetes for example. More information regarding the patient’s sexual history
would need to be asked before concluding a possible sexually transmitted disease. These
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