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Genitourinary Condition Focused Note Assignment

Genitourinary Condition Focused Note Assignment

Episodic/Focused SOAP Note

Patient Initials: Z.Z.

Age: 9 years

Gender: Male

Race: African American

SUBJECTIVE:

CC (Chief Complaint): Painful urination.

History of Present Illness (HPI): Z.Z. is a nine-year-old African American male who presents to the clinic with painful urination. The patient is accompanied by her mother, who highlights that Z.Z. has been experiencing painful urination for the past seven days. Z.Z. rates the pain on a scale of six out of ten. He states that he also experiences difficulty in urination and is scared to urinate because of the pain. When he urinates, he urinates very slowly and takes longer in the washroom. The patient’s mother reports that Z.Z. does not have any other symptoms. However, Z.Z. He states that he sometimes urinates on his clothes when at school because he is unaware of when he urinates. His teacher is aware of his problem because he has strong-smelling urine whose odor can be felt in the entire classroom. The patient’s mother agrees that she is not aware of Z.Z. Urinating on his school uniform because he stays with his mother only during the holidays and some weekends. Z.Z. took over-the-counter painkillers that his father bought, but they only gave him temporary relief. Genitourinary Condition Focused Note Assignment

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Current Medications:

Paracetamol 500mg PRN for migraines

Allergies: No known drug allergy. No known food allergy.

 

Past Medical History (PMH): Z.Z. was last admitted in 2019 for pneumonia. At the age of 2 years, he was admitted for gastroenteritis. Z.Z. was diagnosed with migraines in 2020, which he manages using paracetamol when necessary.

Past Surgical History (PSH): No surgical history.

Personal/Social History: Z.Z. lives with his father on the weekdays and his mother on the weekends and holidays. His parents are divorced. He is in grade 4 at the neighborhood school. He loves going to school and playing with his friends. He likes riding his bicycle at the park with his friends on the weekends and holidays. Z.Z. has been exposed to alcohol and tobacco during family events but never used them. He believes alcohol and tobacco are not good for one’s health. Z.Z.’s parents ensure he takes a healthy meal every day. He rarely eats processed foods. Genitourinary Condition Focused Note Assignment

Immunization History: His immunization is up to date.

Family History: Z.Z is an only child. His parents are alive and healthy. His paternal grandparents died of diabetes complications. His maternal grandfather died of hypertension, while his maternal grandmother is alive with breast cancer.

 ROS:

General: Denies chills, fever, headache, day sweats, fatigue, daytime sleepiness, weight loss, or weight gain.

HEENT/Neck: Denies difficulty swallowing and rhinorrhea. Denies double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion.

Skin: Denies rashes and itching.

Cardiovascular: Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Reports painful urination, difficulty urinating, urinary incontinence, decreased stream, and strong-smelling urine. Denies dribbling and blood in the urine. The patient is uncircumcised.

Neurological: Denies memory loss, headache, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, spells of blindness, or dizziness.

Musculoskeletal: Denies muscle pain, back pain, stiffness, or joint pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatic: Denies swollen lymph nodes or splenectomy.

Endocrinology: Denies weight gain, weight loss, hair loss, hot flushes, and frequent urination.

Psychiatric: Denies history of suicidal thoughts, depression, bipolar disorder, and any other mental health problem. Genitourinary Condition Focused Note Assignment

OBJECTIVE:

Physical Exam:

Vital signs: BP 100/80 mmHg, HR-72 bpm, SPO2- 97% on room air, Temp 98.3, RR-19 bpm, Height- 133cm, Weight- 30kgs, BMI 17.

General: The patient is cooperative, hygienic, and well dressed. He is aware of his surroundings and positively identifies the date, year, and day of the week. He appears uncomfortable.

HEENT: Clear oronasophaynx, PERRLA, normocephalic head, no visual acuity issues.

Neck: Neck has a full range of motion in all directions, normal symmetry, normal length, and no palpable lymph nodes.

Respiratory: On palpation, no tenderness or palpable mass. On auscultation, normal breath sounds without wheezing or audible breath sounds. No chest deformities.

Heart/Peripheral Vascular: On palpation, normal heart size and normal heart location. On auscultation, normal heart rate, normal rhythm, and no murmurs. Normal extremities.

Abdomen: On palpation, abdominal tenderness. Liver and spleen of normal size, normal tenderness, and normal consistency.

Genital/Rectal: This exam was not conducted.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: He is aware of context and oriented to time and place.

Skin: His skin tone is appropriate to his ethnicity.

Diagnostic results:

Urinalysis: Recommended to identify if Z.Z. is febrile. Culture results showed bacteriuria.

Complete blood count: Results showed increased white blood cell count.

Ultrasonography: Recommended to rule out epididymitis.

Suprapubic aspiration: This procedure has been recommended for collecting urine specimens since Z.Z. uncircumcised with a tight foreskin (Bono & Reygaert, 2021)Genitourinary Condition Focused Note Assignment.

ASSESSMENT:

Differential Diagnosis (DDx):

Urinary tract infection: This is an infection characterized by fever, abdominal pain, vomiting, urinary urgency, urinary incontinence, dysuria, strong-smelling urine, enuresis, and urinary frequency (Bono & Reygaert, 2021). Urinary tract infection is a differential diagnosis because of Z.Z. presents with painful urination, difficulty urinating, urinary incontinence, decreased stream, and strong-smelling urine. Diagnostic results showed bacteriuria.

Epididymitis: This is an inflammation of the epididymis. Patients diagnosed with epididymitis present with dysuria, urethral discharge, fever, chills, scrotal pain, scrotal swelling, urinary frequency, and urinary urgency (Rupp & Leslie, 2022). Epididymitis is a differential diagnosis because of Z.Z. presents with gastrointestinal symptoms such as dysuria and difficulty urinating. Bacteriuria signifies epididymitis. This differential diagnosis is ruled out by ultrasonography showing normal-sized epididymis and no abnormalities.

Urethritis: This is an inflammation of the urethra characterized by urethral discharge, dysuria, stinging sensation, and pain in the testicles (Young et al., 2022)Genitourinary Condition Focused Note Assignment. This is a differential diagnosis because Z.Z. experienced dysuria and painful urination. Urethritis was ruled out by patient history and imaging.

 Reflections: I concur with Z.Z.’s management. However, I would have collected the urine specimen from a midstream when Z.Z. was urinating since he had urinary control. Suprapubic aspiration was recommended before considering other options. I learned the importance of having an interview with children who can express themselves instead of only depending on the history from the parent. The patient is under age; therefore, his parent was requested to consent to his treatment plan.

PLAN:

Therapeutic interventions: The primary diagnosis is uncomplicated urinary tract infection. Z.Z.’s therapy aimed to replenish lost fluid and electrolytes and eradicate the infective organism. The patient was prescribed oral rehydration solutions to replenish lost fluid and electrolytes (Vega & Avva, 2022). His prescription had amoxicillin/clavulanic acid and oral rehydration solutions for five days.

Referrals: The patient and his mother are referred to a child counselor to assess his living conditions and environment.

Patient education: Z.Z.’s mother is advised on the importance of completing an antibiotic course and the disadvantages of antibiotic resistance (Shrestha et al., 2021). Circumcision is recommended for its health benefits(Bono & Reygaert, 2021)Genitourinary Condition Focused Note Assignment.

Follow-up: A follow-up appointment is scheduled in one week to determine the patient’s response to treatment and the need to refer to a urologist.

References

Bono MJ, Reygaert WC. Urinary Tract Infection. [Updated 2021 Jun 23]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470195/

Rupp TJ, Leslie SW. Epididymitis. [Updated 2022 Feb 14]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430814/

Shrestha J, Zahra F, Cannady, Jr P. Antimicrobial Stewardship. [Updated 2021 May 28]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572068/

Vega RM, Avva U. Pediatric Dehydration. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436022/

Young A, Toncar A, Wray AA. Urethritis. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537282/ Genitourinary Condition Focused Note Assignment

To prepare:

  • Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
  • Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
  • Select a patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.

Assignment

  • Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?Genitourinary Condition Focused Note Assignment

Please see attached focus note template and checklist. Please read the instructions and information required for each part on the template and cover all the information required in each part of the Template. Provide reference to support Diagnostic tests and Differential diagnosis.

Feel free to use any chief complaint related to gastrointestinal or genitourinary condition

Please follow this example when completing the Diagnostic, assessment, and plan section.

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Diagnostic results:

Please list diagnostic results and diagnostics that need to be obtained and support by references

Assessment.

Primary Diagnosis: first and 2 or 3 differentials diagnosis (say why you chose and support by references)

Plan (Please it is important to cover all the contents and use heading for each section as follow.

  • Additional tests
  • Therapeutic interventions: (pharmacologic and non-pharmacologic)
  • Education
  • Referral:
  • Disposition/Follow up:
  • Reflection: (Do you agree or disagree with preceptor treatment plan, What would you do differently in a similar patient evaluation. New things learned)Genitourinary Condition Focused Note Assignment