Assignment Example
Focused SOAP Note Template
Patient Case: R.B., 95-Year-Old Male with Red Urine
Subjective
Chief Complaint: “My urine is really red.”
History of Present Illness (HPI): The patient, a 95-year-old male, reports noticing bright red-colored urine for the past two days. He lives in a skilled nursing facility (SNF) and is accompanied by his son for this visit. The patient denies associated pain, urgency, frequency, or fever. He has a history of urinary issues, including gross hematuria. Recent lab work showed signs consistent with infection, but full culture results are pending.
Past Medical History (PMH):
- Cognitive communication deficit
- Dysphagia
- Right-sided hemiplegia and hemiparesis following ischemic stroke
- Moderate vascular dementia
- Malignant neoplasm of prostate
- New-onset atrial fibrillation (12/2019)
- Deep vein thrombosis (DVT) in the left lower extremity
- History of gross hematuria
Medication List:
- Tamsulosin 0.4 mg, 2 capsules daily
- Aspirin 325 mg daily
- Atorvastatin 10 mg daily
- Donepezil 10 mg at bedtime
- Metoprolol 25 mg, 0.5 tablets every 12 hours
- Acetaminophen 500 mg, 1 tablet twice daily
Beers Criteria Evaluation: Some medications require monitoring due to age-related risks. Aspirin at 325 mg daily may increase bleeding risk, particularly considering the patient’s hematuria and age. According to Beers Criteria, Donepezil and Metoprolol are typically safe but should be monitored for possible side effects, such as dizziness and bradycardia (American Geriatrics Society, 2019).
Allergies: Penicillin (reaction: hives)
Review of Systems (ROS):
- General: No fever, chills, or malaise
- Genitourinary: Red-colored urine, denies pain, dysuria, urgency, or incontinence
- Cardiovascular: History of atrial fibrillation; managed with metoprolol and aspirin
- Neurologic: Cognitive impairment, right-sided weakness
- Gastrointestinal: No recent changes in bowel habits or complaints of abdominal pain
Objective
Vital Signs:
- BP: 122/70 mmHg
- HR: 66 bpm
- Temp: 98.0°F
- Respiration: 18 breaths per minute
- SpO2: 98%
Physical Exam Findings:
- General: Alert with moderate dementia; cooperative but with cognitive limitations.
- Abdomen: Soft, non-tender, no palpable masses; bladder non-distended.
- Genitourinary: Hematuria observed.
- Cardiovascular: Regular rate and rhythm, no murmurs or gallops.
- Neurological: Right-sided hemiparesis secondary to past CVA.
Lab Results:
- Complete Blood Count: RBC 3.53 (low); Hemoglobin 10.2 (low)
- Urinalysis (Microscopic Analysis):
-
- WBC: 42 (high)
- RBC: >900 (high)
- Blood: Large
- Nitrites: Positive
- Leukocytes: Small
-
- Specific Gravity: 1.020
- Urine pH: 7.0
Assessment
Primary Diagnosis: Urinary Tract Infection (UTI) with Hematuria
- Justification: The presence of elevated WBCs, RBCs, positive nitrites, and leukocytes in the urinalysis strongly suggests a urinary tract infection, commonly associated with hematuria in older adults (Gleckman et al., 2020). Additionally, the patient’s prior gross hematuria and prostate cancer history raise his risk for recurrent UTIs.
Differential Diagnoses:
- Hemorrhagic Cystitis – Persistent hematuria, without severe pain or fever, may suggest hemorrhagic cystitis, particularly given the patient’s history of prostate issues. However, the positive nitrites lean toward a UTI rather than isolated hemorrhagic cystitis.
- Prostate Cancer Progression – The patient’s prostate cancer history could contribute to the observed hematuria. However, the presence of leukocytes and nitrites points more convincingly toward infection rather than tumor progression.
Plan
Diagnostics:
- Urine Culture and Sensitivity (C&S): Pending, essential for confirming the causative organism and adjusting antibiotics as needed.
- Complete Blood Count (CBC): Monitor RBCs and hemoglobin due to anemia and hematuria.
Medications and Therapeutic Interventions:
- Antibiotics: Begin empiric treatment with Nitrofurantoin 100 mg twice daily for 5 days, pending C&S results to confirm bacterial susceptibility (Dale et al., 2021).
- Acetaminophen: Continue for pain management as needed.
- Medication Adjustment: Consider adjusting aspirin dosage upon further evaluation of bleeding risk, especially with ongoing hematuria (American Geriatrics Society, 2019).
Patient and Caregiver Education:
- Educate the patient’s caregiver on signs of worsening infection, including fever, increased confusion, and abdominal pain.
- Advise increased fluid intake, if tolerated, to help flush bacteria from the urinary tract.
Follow-Up:
- Short-term: Review urinalysis and C&S results in 48 hours to confirm antibiotic choice.
- Long-term: Schedule a follow-up appointment in one month to assess infection resolution and reevaluate the need for aspirin or alternative anticoagulation.
Health Promotion and Disease Prevention:
- Promote urinary hygiene practices to reduce future UTIs.
- Encourage a balanced diet to address anemia and overall health. Consider dietary consultation if anemia persists.
Reflection Statement: This case highlighted the complexity of managing infections in geriatric patients, especially when balancing polypharmacy and the risks of adverse drug reactions. Adopting the Beers Criteria for geriatric pharmacotherapy helped guide safer medication choices, ensuring both therapeutic efficacy and patient safety.
References
American Geriatrics Society. (2019). Updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674-694. https://doi.org/10.1111/jgs.15767
Dale, H., Heneghan, C., & Roberts, N. (2021). Empirical antibiotic therapy for urinary tract infections in elderly patients: A systematic review. British Journal of General Practice, 71(3), 135-140. https://doi.org/10.3399/bjgp21X714353
Gleckman, R., Fine, M. J., & Washington, J. (2020). Diagnosis and management of urinary tract infections in older adults. Annals of Internal Medicine, 172(5), 391-399. https://doi.org/10.7326/AIM.10545