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911Doctor
911Doctor, Doctor
Category: Health
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Experience:  Board Certified Emergency Physician
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Need help writing a soap note on a focused visit for a 20-year-old

Customer Question

Need help writing a soap note on a focused visit for a 20-year-old female patient. The patient presents with the symptom of dysuria. Detail the situation by developing the history and physical examination findings and documenting the subjective and objective data
Submitted: 1 year ago.
Category: Health
Expert:  911Doctor replied 1 year ago.

911Doctor :

Welcome, My answers are for educational purposes only. Remember please, that we do not get paid if you do not click 'accept' / give positive ratings!

911Doctor :

do you have an outline yet?

911Doctor :

here's what i think is essential in each sectoin

911Doctor :

subjective

911Doctor :

age

911Doctor :

prior pregnancies

911Doctor :

last menstrual cycle

911Doctor :

associated symptoms, dysuria, fever? flank pain? nausea or vomiting?

911Doctor :

abdominal pain? vaginal bleeding or discharge?

911Doctor :

objective

911Doctor :

vital signs, note any abnormal

911Doctor :

blood in urine?

911Doctor :

general appearance (well appearing?

911Doctor :

flank pain with palpation?

911Doctor :

suprapubic tenderness?

911Doctor :

urinalysis or dipstick

911Doctor :

send urine for culture

911Doctor :

if young and healthy would only get pregnancy test

911Doctor :

if febrile or with flank or back pain might also get CBC though these are rarely helpful

911Doctor :

assessment

911Doctor :

if only urine infection and not pregnant and no flank pain then dx is UTI or Cystitis if blood

911Doctor :

treatment would be with cipro or septra

911Doctor :

follow up if worse

911Doctor :

could also give pyridium as a urinary tract anesthetic (this is part of plan)

911Doctor :

if flank pain consider dx of pyelonephritis and levaquin might be beter choice

911Doctor :

if simple utie, fluids and meds and home, follow up if worse, fever, back pain, vomiting

911Doctor :

please let me know if you have questions about my answer.

911Doctor :

best

911Doctor :

if pyelo, levaquin, nausea medicine like phenergan, tyelenol, fluids, home and recheck next day

Customer: replied 1 year ago.


How soon would you have pt follow up if prescribed septra?

Expert:  911Doctor replied 1 year ago.

if for simple urinary tract infection and the patient improves and feels well there is no in person follow up needed though a phone call in a day or two would be nice.

 

if for kidney infection (pyelonephritis), septra is not the right drug, levaquin would be better, and follow up next day. often pyelonephritis patients are admitted to the hospital so this would be a good idea to follow up next day.

 

best

 

911Doctor, Doctor
Category: Health
Satisfied Customers: 5094
Experience: Board Certified Emergency Physician
911Doctor and 4 other Health Specialists are ready to help you
Customer: replied 1 year ago.

One last question. how much fluid would be recommended for intake?

Expert:  911Doctor replied 1 year ago.

good question. a simple way to recommend proper hydration is to tell the patient to drink enough water to make their urine a light yellow color. caffeinated drinks will make hydration harder as they cause diuresis, so water is best for hydration.

 

best

 

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