NRNP 6552 Week 5 Case Study Discussion Paper

Episodic/Focused SOAP Note Template

Patient Information:
BL, 91-year-old African American/Black female
S.
CC (chief complaint): “Urinary frequency and urgency”
HPI: BL is a 91-year-old African American female who visited the facility with a complaint of urinary frequency and urgency. BL reports that when she urinates, there are only drops of urine. She reported hematuria in the morning. The symptoms started three days ago. She denied any pain. BL also reported a recent odor from her vaginal area for the past three days, which she attributed to a pessary device.
Current Medications: BL currently uses Dirtopan 10 mg once daily for overactive bladder, OTC Centrium multi-vitamin, and Tylenol 650 mg PO Q6-8 hours for arthritic pain.

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Allergies: BL denied any food, drug, or environmental allergies.
PMHx: BL has a past medical history of an overactive bladder, arthritis, and prolapsed bladder in which a pessary device was inserted. She has had the pessary device for the last four years. She has a surgical history of hysterectomy, cholecystectomy, and appendectomy. She reports that her immunization records are up-to-date. She does not remember the last time she received the tetanus vaccine.

Soc & Substance Hx: BL retired 12 years ago as a school superintendent. She lives with her 68-year-old daughter who is a retired school teacher. She stopped driving two years ago. She ambulates with a cane and requires some assistance with her activities of daily living. She does not smoke, drink, or engage in any illicit drugs.
Fam Hx: BL has four living daughters and 2 deceased children. She is widowed. She denied any family history of chronic illnesses.
Surgical Hx: BL has a surgical history of cholecystectomy, hysterectomy, and appendectomy.
Mental Hx: BL denies a history of mental health diagnoses or treatments.
Violence Hx: BL denies a history of any form of physical, emotional, or social violence.
Reproductive Hx: BL is post-menopausal. She has four living children and two deceased. She is widowed. She reports urinary frequency and urgency. She also reports a recent odor from her vaginal area for the last three days. She has a history of an overactive and prolapsed bladder. She has a pessary device that was inserted for the prolapsed bladder. BL also has a history of hysterectomy.
ROS:
GENERAL: B.L. is dressed appropriately for the clinical visit. She is alert and oriented to herself, others, time, and events. She walks using a cane. BL denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: BL denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: She denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: BL denies rash or itching.
CARDIOVASCULAR: She denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: She denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: BL denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: She denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: She walks with a cane. She denies muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: She denies anemia, bleeding, or bruising.
LYMPHATICS: She denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: She denies reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: BL reports urinary urgency and frequency. She also reports drops of urine on urination. BL also reports an odor from her vaginal area. She denies dysuria.
ALLERGIES: She denies a history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: T 97.8, BP 110/64, P 76, Ht 5’04’, Wt 142 lbs
General: The patient is alert and oriented to herself, time, and events. She is dressed appropriately for the occasion. She walks with a cane. There are no signs of observable distress.
Respiratory: Absence of nasal flaring, wheezes, crackles, inspirational stridor, or rhonchi.
Cardiovascular: Absence of peripheral edema and S3 and S4 heart sounds. Presence of S1 and S2 heart sounds.
Genitourinary: Presence of an odor from the vaginal area. The client has an indwelling pessary device. She drains cloudy urine with a strong smell. There is no evidence of trauma to the vaginal area. There is no hematuria.
Diagnostic results: Urinalysis and urine culture were ordered.
A.
Primary and Differential Diagnoses
Uncomplicated urinary tract infection (N39.0): BL’s primary diagnosis is uncomplicated urinary tract infection. Patients with uncomplicated urinary tract infections present to the hospital with complaints that include urinary urgency, frequency, hesitancy, and hematuria. They might also complain of dysuria, suprapubic pain, and bladder spasms (Bono et al., 2023; Schuiling & Likis, 2022). BL has symptoms of uncomplicated urinary tract infections such as no pain or fever and the presence of urgency, frequency, and hesitancy.
Complicated urinary tract infection (N39.0): Complicated urinary tract infection is a differential diagnosis that should be considered for BL. Patients with complicated urinary tract infections present to the hospital with complaints such as dysuria, urgency, frequency, hesitancy, hematuria, flank pain, nausea, vomiting, and fever (Wagenlehner et al., 2020). These symptoms are not evident in the case study.
Pyelonephritis (N11.1): Pyelonephritis is the other differential diagnosis that should be considered for BL. Pyelonephritis refers to bladder infection by bacteria that causes urinary tract infections. Patients report symptoms such as flank pain, fever, vomiting, dysuria, nausea, urgency, and frequency (Belyayeva & Jeong, 2023). The client does not have symptoms such as fever and flank pain, hence, ruling out pyelonephritis.
Sexually transmitted infections (A64): The other differential diagnosis to be considered for BL is a sexually transmitted infection. Patients with sexually transmitted infections present to the hospital with complaints such as fever, purulent, yellow vaginal discharge, and symptoms of urinary tract infections, which are not evident in the case study (Kreisel et al., 2021).

P.
Urinalysis and urine culture will be obtained from BL. She will be referred for a urologist review because of her overactive bladder. The therapeutic interventions adopted include prescribing her oral nitrofurantoin 50 mg once daily. She will be educated on the importance of maintaining optimum hydration to clear the bacteria, avoiding douching, and ensuring treatment adherence (Bono et al., 2023; Schuiling & Likis, 2022). I agree with the preceptor’s diagnosis of an uncomplicated urinary tract infection. This is based on the symptoms that align with those seen among patients with the uncomplicated infection. I learned about the importance of comprehensive patient assessment and history taking from this case. I also learned about the importance of using evidence-based data to rule in or out diagnoses. I will assess the patient for other symptoms of urinary tract infections such as confusion should I experience a similar care. Elderly patients present to the hospital with confusion if they have a complicated urinary tract infection.

References
Belyayeva, M., & Jeong, J. M. (2023). Acute Pyelonephritis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519537/
Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2023). Uncomplicated Urinary Tract Infections. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK470195/
Kreisel, K. M., Spicknall, I. H., Gargano, J. W., Lewis, F. M., Lewis, R. M., Markowitz, L. E., Roberts, H., Johnson, A. S., Song, R., Cyr, S. B. St., Weston, E. J., Torrone, E. A., & Weinstock, H. S. (2021). Sexually Transmitted Infections Among US Women and Men: Prevalence and Incidence Estimates, 2018. Sexually Transmitted Diseases, 48(4), 208–214. https://doi.org/10.1097/OLQ.0000000000001355
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning Wagenlehner, F. M. E., Bjerklund Johansen, T. E., Cai, T., Koves, B., Kranz, J., Pilatz, A., & Tandogdu, Z. (2020). Epidemiology, definition and treatment of complicated urinary tract infections. Nature Reviews Urology, 17(10), Article 10. https://doi.org/10.1038/s41585-020-0362-4

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COMMON GYNECOLOGIC CONDITIONS, PART 2

Case studies provide the opportunity to simulate realistic scenarios involving patients presenting with various health problems or symptoms. Such case studies enable nurse learners to apply concepts, lessons, and critical thinking to interviewing, screening, diagnostic approaches, as well as to the development of treatment plans.

For this Case Study Discussion, you will develop a case study that demonstrates a gynecological disease process from your practicum experience or your professional practice that would be quite challenging for you as a clinician. You will then explore this case study to determine the diagnosis, diagnostic tests, and treatment options for the patient

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To prepare:

Consider a case study related to a patient that demonstrates a gynecological disease process in your practicum experience or professional practice that would be your biggest challenge as a clinician. Note: Possibly use your “FNP or AGPCNP Skills and Procedures Self-Assessment” in your practicum experience to guide your case study selection.

Review the Learning Resources for this week and specifically review the clinical guideline resources specific to your proposed case study.

Use the Focused SOAP Note Template found in the Learning Resources to support your discussion. Complete a Focused SOAP note and critically analyze this and focus your attention on the diagnostic tests.

BY DAY 3

Based on your case study, post the following:

POST A Focused SOAP NOTE only and describe your case study.

Provide a differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

Define what you believe is the most important diagnosis. Be sure to include the priority in conducting your assessment.

Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

Also, share with your colleagues your experiences as well as what you learned from these experiences.

Use your Learning Resources and/or evidence from the literature to support your thinking and perspectives.

Read a selection of your colleagues’ responses.