SOAP Notes for UTI

R.B.is a 95-year-old white male, currently living in a skilled nursing facility (SNF)

Chief complaint: “My urine is really red.”

HPI: On Wednesday (2 days ago), the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.

Allergies: Penicillin: Hives

Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID

Code status: DNR

Diet: Regular diet, pureed texture, honey-thickened liquids

Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%

PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-sided hemiplegia and hemiparesis from a previous ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on the left lower extremity, gross hematuria

Labs:

RBC                         3.53 (L)

Hemoglobin           10.2 (L)

Microscopic Analysis, Urine, straight cath

Component:

WBC UA                                    42 (H) (0-5/ HPF)

RBC, UA                                    >900 (H) (0-5/HPF)

Epithelial cells, urine               2           (0-4 /HPF)

Hyaline casts, UA                     0           (0-2 /LPF)

Urinalysis

Color                           Red

Appearance (Urine)     Clear

Ketones, UA                 Trace

Specific gravity             1.020               (1.005-1.025)

Blood, UA                     Large

PH, Urine                      7.0       (5.0-8.0)

Leukocytes                   Small

Nitrites                         Positive

C&S results were not available yet.

Please include differential diagnosis with explanation and citation.

Answer

Focused SOAP Note

Patient Information:

Initials: R.B

Age: 95

Sex: Male

Race: White

S (subjective)

CC: “My urine is really red.”

HPI: R.B., a 95-year-old caucasian male, was brought by his son with concerns regarding the appearance of his urine. Upon using the restroom and observing the vibrant red coloration, he became aware of this change for the first time. The onset of this symptom occurred approximately two days ago suddenly. According to R.B., his urine consistently has a uniformly bright red hue without any observable clots or particles. No accompanying signs or symptoms exist, such as pain during urination, urgency, or discomfort. R.B. also mentions that there is no specific activity or event linked to the timing of this occurrence; nevertheless, it has remained consistent over the past two days. Regarding exacerbating or alleviating factors, R.B. has not identified any particular activities that cause an aggravation or bring relief from these symptoms. R.B. rates his level of concern as seven on a scale of 1 to 10 because this change’s sudden and unfamiliar nature is unsettling to him.

Current Medications:

  • Tamsulosin 0.4 mcg is prescribed as two capsules to be taken daily to manage benign prostatic hyperplasia and improve urinary flow. The patient has been regularly using this medication for three years.
  • Aspirin 325 mg is administered daily as an anticoagulant to prevent stroke due to the patient’s medical history involving ischemic CVA. This medication has been part of the patient’s regimen for five years.
  • Atorvastatin 10 mg daily provides cholesterol control and cardiovascular support. Its prescription was initiated four years ago after routine laboratory tests revealed elevated cholesterol levels.
  • Donepezil 10 mg is orally consumed once at night to alleviate cognitive symptoms associated with vascular dementia, initiated approximately two years ago.
  • Metoprolol 25-mg in half-tablet doses every twelve hours as a beta-blocker for managing hypertension and safeguarding cardiac health post-heart attack diagnosis in 2019.
  • Acetaminophen 500 mg: 1 tablet BID for arthritis pain and occasional headaches. OTC, used as needed.

Allergies:

Penicillin causes the patient hives, described as raised, itchy welts on the skin.

No known food or environmental allergies

PMHx:

Immunization status: Flu shot received annually, last tetanus shot in 2015.

Past major illnesses: ischemic CVA resulting in hemiplegia and hemiparesis, vascular dementia, and atrial fibrillation (12/2019), DVT on the lower extremity, gross hematuria

Surgeries: Prostate surgery for malignant neoplasm six years ago.

Soc and Substance Hx:

  • Occupation: Retired school teacher
  • Hobbies: They enjoy reading and engaging in gardening activities, although these hobbies are somewhat limited due to their hemiplegia condition.
  • Family status: a widower with two children.
  • Tobacco use: A previous smoker for three decades before quitting 25 years ago.
  • Alcohol consumption habits: Occasionally indulges in a single glass of wine without any past instances of excessive alcohol intake.
  • Health promotion Question: Regularly utilizes seat belts when traveling, ensures the presence of smoke detectors within their living space at the SNF, and refrains from using cell phones during transportation.

Fam Hx

– Father: Passed away due to myocardial infarction in his 70s.

– Mother: Lived till 90, passed due to natural causes.

– Siblings: One brother who passed from complications of diabetes in his late 80s.

– Children: Two children, both alive and healthy.

– Grandchildren: Three grandchildren, no significant health issues mentioned.

Surgical Hx: Prostrate surgery

Mental Hx: – Diagnosed with vascular dementia, currently managed with Donepezil.

– No history or current concerns of anxiety, depression, self-harm practices, or suicidal or homicidal ideation.

Violence Hx: no known issues about safety (personal, home, community, sexual (current and historical).

Reproductive Hx: Widowed and did not mention any issues or concerns related to sexual health

ROS:

GENERAL: Reports no unintentional weight loss, no chills or fever, some fatigue likely related to age and existing conditions, and no recent changes in overall strength or energy.

HEAD: Denies any head trauma frequent or new headaches.

EENT (eyes, ears, nose, and throat):

Eyes: No complaints of visual changes blurred or double vision. No yellowing of sclera. No history of cataracts or glaucoma.

Ears: No complaints of hearing loss or ringing in the ears.

Nose: No recent episodes of epistaxis, no congestion, or rhinorrhea.

Throat: No sore throat, hoarseness, or difficulty swallowing.

SKIN: Skin is intact, no rash, no itching, no recent changes in moles or skin lesions.

CARDIOVASCULAR: No new chest pain or discomfort. Denies palpitations. No known edema.

RESPIRATORY: No complaints of shortness of breath or cough. No history of asthma or COPD.

GASTROINTESTINAL: The appetite is good. Denies nausea, vomiting, diarrhea, or constipation. No blood in the stool or black tarry stools.

GENITOURINARY: Main complaint of red-colored urine (hematuria). Denies burning on urination or increased frequency.

NEUROLOGICAL: History of ischemic CVA, resulting in R-sided hemiplegia. No recent episodes of dizziness, syncope, seizures, or tremors. No changes in bowel or bladder control.

MUSCULOSKELETAL: Reports occasional joint pain, especially in the mornings. No back pain, muscle pain, or recent injuries.

HEMATOLOGIC: Labs indicate potential anemia. No known bleeding disorders or easy bruising.

LYMPHATICS: Denies enlarged lymph nodes or any known history of lymphedema.

PSYCHIATRIC: Diagnosed with vascular dementia. Denies feelings of depression, anxiety, or other mood changes.

ENDOCRINOLOGIC: Denies excessive thirst (polydipsia) or excessive urination (polyuria). No known history of diabetes or thyroid disease.

REPRODUCTIVE: Aged 95, no recent sexual activity reported. No known concerns with reproductive health.

ALLERGIES: Allergic to Penicillin, which causes hives. There is no history of asthma, seasonal allergies, or other known drug allergies.

O (Objective)

Physical Exam:

VITAL SIGNS:

B.P.: 122/70 mmHg Heart Rate: 66 bpm, regular rhythm, Temperature: 98.0°F, Respiratory Rate: 18 breaths/min, Oxygen Saturation: 98% on room air

GENERAL: The elderly patient is alert and oriented x3, appears his stated age, and is in no acute distress. Given his cognitive communication deficit, he is calm, cooperative during the examination, and communicates clearly.

HEAD: The skull is normocephalic and atraumatic. Hair is gray and evenly distributed without signs of alopecia. No scalp tenderness or masses were palpated.

EENT:

Eyes: Pupils are equal, round, and reactive to light. Conjunctivae are pink and moist without pallor or icterus. No nystagmus or exophthalmos was noted.

Ears: External ears are symmetrical without masses or lesions. No drainage was noted from either ear.

Nose: No nasal discharge, septum midline.

Throat: The Oropharynx is moist without erythema or exudate.

NECK: Supple, with full range of motion. No jugular venous distension. Trachea midline. No palpable lymphadenopathy or masses.

CARDIOVASCULAR: Heart rhythm is regular; no murmurs or gallops are heard on auscultation. Pulses are 2+ and symmetrical in all extremities. Capillary refill is less than 2 seconds in all digits.

RESPIRATORY: Lungs clear to auscultation bilaterally, with symmetric chest expansion. No wheezes, rhonchi, or crackles were heard.

GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended. Bowel sounds are present and normoactive in all four quadrants. No hepatosplenomegaly upon palpation.

GENITOURINARY: The external genitalia appear to be age-appropriate. The absence of the prostate on rectal examination is consistent with his prior prostatectomy for prostate cancer. There are no signs of inflammation, nodules, or masses at the surgical site.

MUSCULOSKELETAL: Demonstrates right-sided weakness as per his previous ischemic CVA. Full range of motion in left extremities. No joint deformities were noted.

NEUROLOGICAL: Cranial nerves II-XII are grossly intact. Demonstrates right-sided facial droop. Muscle strength is 3/5 on the right side and 5/5 on the left.

SKIN: Warm and dry to the touch. No rashes, ulcers, or notable lesions. Good skin turgor.

Diagnostic Results:

Complete Blood Count (CBC):

RBC: 3.53 (L), suggesting potential anemia.

Hemoglobin: 10.2 (L)

Urinalysis:

Color: Red, indicating the presence of blood.

Specific Gravity: 1.020

Blood: Large amounts present, confirming hematuria.

P.H.: 7.0

Leukocytes: Small amounts.

Nitrites: Positive, which can indicate a urinary tract infection.

Microscopic Analysis of the Urine:

WBC UA: 42 (H), suggesting inflammation or infection.

RBC UA: >900 (H) confirming gross hematuria.

Epithelial cells: 2

A (Assessment)

Differential Diagnoses:

Urinary Tract Infection (UTI): A urinary tract infection is a condition that affects the bladder, urethra, kidneys, and ureters, among other parts of the urinary system (Fath-Bayati et al., 2023). UTIs can cause painful urination (dysuria), frequent urinal urges (urinary frequency), and urgency (Kornfält Isberg et al., 2020). In severe cases, gross hematuria is visible blood in the urine, mainly when it affects the kidneys (upper urinary tract). UTIs are especially dangerous for older adults because they can cause systemic symptoms and progress to urosepsis, a potentially fatal condition. In R.B.’s case, elevated white blood cells in the urine and positive nitrites point to a urinary tract bacterial infection. Given R.B.’s age and clinical presentation, a UTI diagnosis is critical.

Bladder or Kidney Stones (Urolithiasis): “Urolithiasis” refers to solid mineral and salt deposits in the urinary system, including kidney and bladder stones. Among other areas of the urinary tract, they can develop in the kidneys, ureters, bladder, or urethra (Malhotra et al., 2022). The severe hematuria observed in R.B.’s case may be due to stones, which can irritate and harm the lining of the urinary tract and result in blood appearing in the urine. These stones can cause mild discomfort or excruciating pain depending on size and location. Given R.B.’s age group, there is an increased risk of stone formation because of decreased fluid intake, underlying medical conditions, and medication side effects. Intervention may be required, either through fragmentation or surgical removal, if a stone prevents normal urine flow or causes persistent symptoms (Etienne Xavier Keller et al., 2021).

Bladder Cancer: Gross hematuria, characterized by blood in the urine, is a prevalent indication of bladder cancer (Liang et al., 2022). It is essential to thoroughly investigate and eliminate other potential causes, such as malignancies affecting the bladder or other parts of the urinary tract, particularly considering this patient’s age and previous diagnosis of prostate cancer. The American Urological Association states that individuals with risk factors like advanced age and smoking history should be especially vigilant in ruling out bladder cancer when experiencing gross hematuria (Willis and Tewelde, 2019).

P (plan)

Diagnostic Studies: The urine culture and sensitivity results are being awaited to determine the appropriate antibiotic therapy.

Therapeutic Interventions: Commence empirical antibiotic therapy, considering the patient’s penicillin allergy. A suitable option may be Ciprofloxacin 500 mg, taken orally twice daily for seven days. Adjust the antibiotic choice based on the culture and sensitivity testing results.

Education: Educate R.B. on the significance of completing the entire course of antibiotics, even if symptoms improve. Provide instructions regarding indicators suggestive of a worsening UTI, such as fever, flank pain, or increased confusion.

Follow-up: Schedule a follow-up appointment in one week to ensure resolution of symptoms and adequate treatment response to address infection.

Referrals: Consider referring R.B. to a urologist for further evaluation, given their medical history and current symptomatology requiring thorough assessment.

Disposition: Continue monitoring at the skilled nursing facility with close observation for any alterations in mental status or vital signs.

Reflection

This case exemplified the complex nature of caring for elderly individuals. The evaluation of R.B.’s presentation went beyond surface-level symptoms and delved into the underlying factors contributing to their condition. One key realization was understanding the interconnectedness of different health issues, particularly in older adults, emphasizing the need to investigate any symptom thoroughly and not make assumptions based solely on its appearance.

Integrating health promotion and disease prevention into care is vital, particularly for elderly patients. Considering R.B.’s age and Caucasian ethnicity, he belongs to a demographic that faces higher susceptibility to urinary tract infections, notably in post-hospital care settings. Given his medical history and background, taking proactive measures to prevent common geriatric illnesses is crucial. This includes promoting good personal hygiene, encouraging adequate fluid intake, and potentially discussing cranberry supplements or juice, as some studies suggest their potential benefits in UTI prevention. It’s essential also to consider socio-economic and cultural factors that have significant influence but were not explicitly mentioned for R.B. Gaining insights into his background, lifestyle habits, and daily routines can inform tailored preventive strategies specifically designed for him. Regular check-ups, age-appropriate screenings, and consistent family engagement can enhance overall health outcomes for R.B. himself and other individuals in similar situations.

References

Etienne Xavier Keller, Vincent De Coninck, Olivier Traxer, Asaf Shvero, Kleinmann, N., Hubosky, S. G., Steeve Doizi, Hardacker, T., Bagley, D. H., & Sonzogni-Cella, M. (2021). Stones. Springer EBooks, 105–154. https://doi.org/10.1007/978-3-030-82351-1_5

Fath-Bayati, L., Namdari, H., Parvizpour, F., Awad, I., Ghiasi, M., Sefat, F., & Arabpour, Z. (2023, January 1). Chapter 10 – Encapsulation in the Urinary System (F. Sefat, G. Farzi, & M. Mozafari, Eds.). ScienceDirect; Woodhead Publishing. https://www.sciencedirect.com/science/article/abs/pii/B9780128243459000210

Kornfält Isberg, H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2020). Uncomplicated Urinary Tract Infection in Primary Health Care: Presentation and Clinical Outcome. Infectious Diseases, 53(2), 94–101. https://doi.org/10.1080/23744235.2020.1834138

Liang, D., Xiang, Y., SONG, T., Zhou, G., & SHEN, T.-M. (2022). Diabetes Is a Risk Factor for the Prognosis of Patients with Bladder Cancer: a Meta-Analysis. Journal of Oncology, 2022, 1–7. https://doi.org/10.1155/2022/1997507

Malhotra, M., Tandon, P., Wadhwa, K., Melkani, I., Singh, A. P., & Singh, A. P. (2022). The Complex Pathophysiology of Urolithiasis (kidney stones) and the Effect of Combinational Drugs. Journal of Drug Delivery and Therapeutics, 12(5-S), 194–204. https://doi.org/10.22270/jddt.v12i5-S.5718

Willis, G. C., & Tewelde, S. Z. (2019). The Approach to the Patient with Hematuria. Emergency Medicine Clinics of North America, 37(4), 755–769. https://doi.org/10.1016/j.emc.2019.07.01

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