SOAP is a comprehensive documentation use by health care practitioners to write a systematic method of a patient history and physical. The information obtains from the patient complaint develop a diagnosis, plan, and medical management to health problems. The purpose of the assignment involves a comprehensive H&P that takes into considerate the patient signs and symptoms and formatting a plan of action, treatment and management in collaboration with the patient.
Patient Initials: K. K. Age: 48 Gender: Female
Chief Complaint: Fever and Lower Pelvic Pain
History of Present Illness: KK is 49-year-old Caucasian female two weeks S/P TLH present to the office with c/o lower pelvic
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Scalp and hair are wet and wave. Eyes: PERRLA with EOMs intact, active red reflex, sclera white in color, no cataracts or hemorrhage noted. Ears: Tympanic membrane patent, intact bilateral without bulging, no erythema or effusion noted. Nasopharynx: Patent, pink, moist oral mucosa, and no enlargement of nasal turbinates. Throat: soft and hard palate intact, non-tender, tonsils without enlargement, non-tender, and erythema Good dental hygiene.
Neck: AROM, no carotid bruit bilaterally,the trachea is midline, no nodules, lymph or thyroid enlargement or JVD.
Breast: No axillary lymph nodule enlargement, lumps, mass, or nipple discharge noted. Chest/Lungs: CTA in all fields without adventitious sound, chest movement symmetrical nonlabored breathing. Denies chest discomfort on palpation.
Heart/Peripheral Vascular: RRR, S1S2 at the apex, no S2S3 or murmurs heard on auscultation. Bilateral lower extremity edema. Capillary refills < 3sec, pink nail beds, radial and dorsalis pedis pulses palpate equal bilaterally.
Abdomen: Three Surgical lap site clean, dry, intact without drainage or signs of infection. Pain to the lower abdomen pelvic area on palpation. Soft, non-distended, normoactive bowel sounds in all four quadrants. No bruits heard. No hepatomegaly, mass, or splenomegaly on palpation.
Genital: No examination today. Will f/u in another two weeks unless patient c/o foul odor, or heavy vaginal
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Will f/u in another two weeks.
Musculoskeletal: All four extremities have AROM, no joint pain or stiffness observed with motor strength 5/5.
Neurological: Cranial nerves, I-XII intact without tremors. Intact balance and coordination saw during walking.
Mental status: Alert and oriented x4. Speech is clear, spontaneous and, precise. No distorted thinking or impaired judgment.
Psychiatric: Mood display feeling of worried, and concern happy, not easily distracted.
DIAGNOSTIC LAB TESTS:
CBC: Will reveal abnormal finding on the patient WBC indicating an infection.
CMP: Will reveal abnormal finding within the kidney and liver panel.
Urinalysis Analysis/ Urine Cultural: Checking abnormalities in the bladder.
Abdominal Ultrasound: Looks at varies body organs like they kidney, gallbladder, pancreas, spleen, liver checking for abnormal finding, and structure.
ASSESSMENT:
Urinary Tract Infection: “A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra” (Mayo Clinic, 2017).
Cystitis: “is an inflammation of the bladder and is the most common site of UTI” (Huether & McCance,
Examination revealed an oxygen saturation of 98% and blood pressure of 145/90. Oropharyngeal inspection revealed significant crowding (Mallampati class 3) with macroglossia. Chest auscultation was clear and two heart sounds were audible with nil else.
HPI: MR is a 70 y.o. male patient who presents to ER with constant, dull and RUQ abdominal pain onset yesterday that irradiate to the back of right shoulder. Client also c/o nauseas, vomiting and black stool x2 this morning. He reports that currently resides in an ALF; they called the ambulance after his second episodes of black stool. Pt reports he drank Pepto-Bismol yesterday evening without relief. Pt states that he never experienced similar symptoms in the past. Denies any CP, emesis, hematochezia or any other associated symptoms at this time. Client was found with past history gallbladder problems years ago.
Cystitis more commonly known as a urinary tract infection (UTI) or bacteriuria is a chronic infectious disease defined as inflammation of the urinary tract including the bladder and urinary tissue. Signs and symptoms develop due to aggravated epithelial tissue that line the bladder and urinary tract effected by the bacteria infecting them. There is a greater prevalence in women than in men, however when men develop a UTI they are at greater risk for complications such as pyelonephritis or septicemia (Lehne 2013). Bauman (2013) states that 32% of women will experience cystitis in their lifetime. Lehne (2013) states that up to 35% of sexually active females will develop a urinary tract infection each year and that up to 50% of females in nursing homes have cystitis at any given time.
Urolithiasis is the process of forming stones in the kidney, bladder, and/or urinary tract.1 1,200 to 1,400 per 100,000 people will develop a urinary stone each year. Urinary stones are formed when there is a decrease in urine volume or an excess of stone forming substances are present. The use of diagnostic imaging plays a vital role in the diagnostic and treatment processes of a stone in the urinary track. This paper will discuss the signs, symptoms, diagnosis, treatment, and prognosis of Urolithiasis.
J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed, revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed to several abnormal labs.
lip, skin folds at the corners of the eyes, indistinct groove on the upper lip, and an
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.
The New England Journal of Medicine -- February 1, 1996 -- Vol. 334, No. 5
Cystitis is the medical term for inflammation of the urinary bladder. Most of the time, the inflammation is caused by a bacterial infection, and it’s called a urinary tract infection. A bladder infection can be painful and annoying, and it can become a serious health problem if the infection spreads to your kidney.
A urinary tract infection is a very common infection that can happen to anybody. A urinary tract infection usually occurs when bacteria enters the urethra and multiples in the urinary system. The Urinary tract includes the kidneys, the thin tubes that carry urine from the kidneys to the bladder (ureters), and the main tube that carries the urine from the bladder (urethra). Women, men, and children are all immune to this infection. Women have the highest chances of getting it. In the Urinary tract, the main links of the ureters help get rid of any bacteria that tries to enter the urine, and the bladder helps prevent urine from backing up into the kidneys.
Genitourinary system: He doesn’t have pain during urinating and no increase of passing urine and he doesn’t need to get up in the middle of the night to pass urine. There is no blood in the urine.
Urinary Tract Infection, also known as UTI, occurs in two common locations, the bladder and kidneys. The kidneys are important organs that aid in filtering out waste products from blood and maintaining water distribution throughout the body. The waste products are filtered out via bladder, which is the reason of the bladder being the second site for the infection. A normal human being has two kidneys, one on left and right side, a bean shaped organ, and is located at the back of the abdomen. “Each kidney is about 11.5 cm long, 5-7.5 cm broad, 5 cm thick, and weight about 150 grams” (HealthInfoNet, Paragraph 2). Furthermore, a bacterium named Escherichia coli lives in both the kidneys and the GI tract. E. coli is part of the human body and produces
The Urinary System is a simple yet complex system in the body. It has four parts which include, the kidneys, ureters, urinary bladder, and the urethra. This paper will go into depth about the Anatomy and Physiology of The Urinary System and will explain what each of the four parts do for the body. It will also, include some diseases the urinary system can have.
Patient’s personal hygiene is a vital part of the nurse’s role. Young (1991) described cleanliness as a basic human right, not a luxury the need for the patient to physically cleansing and which would include skin, hair and nails.
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.