Advance Nursing Practice Discussion Paper
Chief Complaint– “I have been experiencing stomach cramps, and it hurts every time I have to go to the bathroom.”
History of Present Illness – The patient reports that she has had a history of urinary tract infections that have continued for a few years. The patient notes a progressive increase in dysuria beginning three days ago, as well as a gradual increase in suprapubic discomfort that has lasted for one day. The patient reports that the pain she feels while urination is a seven out of ten, and that she has a consistent four out of ten pain in her suprapubic region across the day. The patient notes that the combination of AZO and Tylenol provided some alleviation Advance Nursing Practice Discussion Paper
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Past Medical History – denies past medical history, or surgical history. Denies getting pregnant. Denies medication, food, or seasonal allergies. All immunizations are current.
Family History –
Mother- Type 2 diabetes
Father-High cholesterol
Grandmother- Dementia
Grandfather- High cholesterol
Social History – The patient has recently finished high school and is about to begin college. The patient has shared that she is considering majoring in economics at the college. The patient says that they do not drink alcohol, take drugs, or smoke. The patient reports that she engages in consistent physical activity and strives to consume meals that are nutritionally sound. The patient lives with both of her parents and does not presently have any paid employment Advance Nursing Practice Discussion Paper
Review of Systems:
General: Denies fever, chills, fatigue, or weakness. Denies weight change.
HEENT: Head: denies headaches. Eyes: denies eye pain, itchy eyes, or discharge. Nose: denies nasal discharge or hearing problems. Throat and mouth: Denies swallowing problems or sore throat.
Respiratory: Denies cough and shortness of breath.
Cardiovascular: Denies palpitations or chest pain.
Gastrointestinal: Reports lower abdominal cramping. Denies nausea, vomiting, constipation, or diarrhea.
Genitourinary: Reports dysuria. Denies polyuria. Denies vaginal discharge.
Musculoskeletal: Denies back pain, muscle pain, or joint pain.
Neurological: Denies numbness or tingling.
Psychiatric: Denies stress or suicidal ideation.
Skin/hair/nails: Denies rash, acne, or lesions Advance Nursing Practice Discussion Paper
Objective
Physical Examination
General: Pleasant and in no acute distress. Appears well-developed, well-nourished, and well-dressed.
HEENT: Head: Autramatic and normocephalic · Eyes: sunken eyes, icteric sclera: pupils EOMI and PERRLA· Ears: clear canals · Nose: Patent · Throat: Moist oral mucosa, Tonstils 2+, no goiter.
Neck: Supple, no lymphadenopathy, no meningismus, no JVD
Cardiovascular: Regular rate and rhythm. No rub, murmur, or gallop.
Respiratory: No cough, wheezing , or, rhonchi.
Breasts: No lumps noted
Gastrointestinal: tender, guarding , soft. No hernia, masses, or trauma noted.
Musculoskeletal: Full range of motion
Neurological: Alert and oriented X3
Genitourinary: LMP-2 months ago. No vaginal bleeding or discharge.
Hair, Skin, & Nails: Pink, dry and warm.
Diagnostic Testing -Positive for nitrites in urine
Primary diagnosis: Urinary Tract Infection
Differential Diagnosis: Advance Nursing Practice Discussion Paper
Pyelonephritis– This is the irritation of the kidney that occurs as a result of bacterial infection. An acute bacterial infection of the urinary system is the root cause of the kidney irritation (Bickley, 2017). The condition starts in the urethra or the bladder and then moves on to affect the kidneys. Some of the symptoms include a high fever, the need to urinate often, and pain in the back, sides, or groin.
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Pelvic Inflammatory Disease– Women under the age of 35 who are sexually active are the ones most likely to get PID (Dains et al., 2016). Peritonitis and other associated symptoms might develop if the infection spreads. Patients who have this ailment often report of pain in the lower abdomen, which may range from mild to severe. Patients may have nausea or vomiting, fever, abnormal bleeding, vaginal secretions, or all three symptoms together. WBC and ESR are almost always at abnormally high levels (Dains et al., 2016). During the evaluation, the patient revealed that she had been having irregular menstrual cycles and abdominal tenderness.
Ureterolithiasis– This is the abrupt onset of acute pain that comes and goes in waves and eventually reaches a severe level (Dains et al., 2016). Pain is often experienced in the lower abdomen or the flanks. Patients may have symptoms such as nausea, vomiting, chills, fever, hematuria, and excessive urine. They may also have hematuria. Because the patient did not have a fever and tested positive for nitrites, the most likely reason is that they have a urinary tract infection.
Plan
- Administer oral fluids and cephalexin 500 mg PO two times daily for 5-7 days.
- Provide the patient with education on how to prevent UTIs and maintain hygiene.
- Order urine culture to check for bacteria.
- Acute pyelonephritis might be considered if symptoms do not go away after treatment or if they return within 2-4 weeks (Dains et al., 2016) Advance Nursing Practice Discussion Paper
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Discussion Question: An 18-year-old female presents to the office complaining of dysuria, and lower abdominal cramping. She has no PMH, no allergies and No Primary Care Provider. LMP 2 months ago. PE reveals suprapubic tenderness on abdominal palpation. Denies flank tenderness on palpation. Develop a SOAP note remember to include the differential Diagnoses and Diagnostics. Then critique the Soap note of the two people who posted before you. (Please try to limit it to two critiques per student if possible.) You must use clinical practice guidelines in your post. Your critique should identify at least one positive and one area for future growth. Lab interpretation: The urine dip reveals Urine Dip COMPONENT RESULT REFERENCE RANGE Dipstick urinalysis Color Dark yellow — Clarity Turbid — pH 7.0 — Specific gravity 1.010 — Glucose Negative Negative Blood Negative Negative Ketones Negative Negative Protein Negative Negative Urobilinogen Negative Negative Bilirubin Negative Negative Leukocyte esterase Positive Negative Nitrite Positive Negative Advance Nursing Practice Discussion Paper