SOAP Note
Emergency Department
Elijah Hanna PA-S
Lock Haven University PA Program
9-4-12
Name: ****** *****
MRN: ********
Race & Gender: Caucasian Male
Insurance: Geisinger Gold
Date Of Birth: 4/4/1937
Date: 9/4/2012
S:
CC: “Blood in my urine since this morning”
HPI: ****** ***** is a 75-year-old Caucasian male presenting to the ED complaining
of blood in his urine starting this morning. He said this has never happened before,
and he was scared when he saw blood throughout his entire void upon waking up
this morning. The patient also complains of increased frequency and nocturia for the
past two days, and denies ever having this before. He says he feels like he has to go
at least once an hour, and about 2-3 times during the past two nights. Patient denies
any dysuria, back or abdominal pain, retention or incomplete voids, weak or
changed stream, changes in urine output, fouls smelling urine, urethral discharge or
pain, or rectal pain or fullness. The patient denied any history of pyelonephritis,
renal disorders, renal lithiasis, urinary tract infections, GI or GU malignancies,
prostatitis, BPH, or STDs. The patient denied any changes in diet or eating beets,
rhubarb, or blackberries. The patient denied any trauma or injury to his abdomen,
back, or penis. He did not try anything to alleviate the symptoms other than drinking
more water, and denies anything making them worse. He has only had one void with
red colored urine, and has not voided since. Patient denies any recent illnesses, and
hasn’t been to his PCP or an ED in over 4 years.
PMH: The patient has a history of hypertension that was diagnosed 10 years ago. He
initially was given blood pressure medication from his PCP, but discontinued it
when he changed providers and hasn’t had medication for the last 4 years. Patient
denies any history of anemia, CAD, DM, CVA, STDs, cancers, renal disorders, GI
disorders, renal lithiasis, urinary tract infections, prostatitis, or BPH.
Immunizations: Up to date. Gets a yearly influenza vaccine.
Injuries: Fractured left radius in 2002.
Surgeries: None.
Hospitalizations: None.
Medications: Bayer Back & Body (chronic osteoarthritis, PRN).
Herbs/Vitamins: Octuvite (eye vitamin).
Allergies: NKDA, No food or environmental allergies known of.
Family History:
Father, Deceased at 74 years old from Alzheimer’s Disease
Mother, Deceased at 84 years old from Lung Cancer
Paternal Grandfather, Deceased at 62 from an MVA
Paternal Grandmother, Deceased at 61 from an MVA
Maternal Grandfather, Deceased at 84 from an MI
Maternal Grandmother, Deceased at 86 from a CVA
Social History: Patient has been happily married to **** ***** for the last 50 years,
and they have two daughters that are alive and well. He stays active playing with his
4 grandchildren and is an avid outdoorsman. He exercises daily with his wife at the
local YMCA where he swims. He worked as a postal worker for 40 years, and is now
retired and financially stable. The patient denies any history of alcohol, tobacco, or
drug use. The patient says he has well-balanced diet, which includes many fruits and
vegetables.
R.O.S.:
General: Patient denies any fevers, weight loss/gain, fatigue, weakness, appetite
loss, chills, difficult sleeping or night sweats.
Skin: Patient denies any rashes, itching, bruising, dryness, redness or lesions.
Patient denies any other changes to hair, skin or nails.
Respiratory: Patient denies any chest pain, dyspnea, cough, sputum production,
hemoptysis, or history of infection of TB.
Cardiac: Patient denies any chest pain, dyspnea on exertion, palpitations, murmurs
or congenital abnormalities/complications.
Abdominal: Patient denies any abdominal or rectal pain, changes in bowel
movement activity or characteristics, light or dark colored stools, or rectal fullness.
Genitourinary: (In HPI)
Musculoskeletal: Patient denies any new or different joint pain, swelling, redness,
or limitations in mobility. Patient denies any muscle pain, weakness, fasiculations,
or atrophy.
O:
Vital Signs: Blood pressure- 212/102mmHg (L arm, sitting), Heart Rate- 84 bpm,
Respiration Rate- 16 bpm, Temperature- 98.8  F (Temporal), SpO2- 97% (Room
air), Weight- 88.45 kg (195 lb), Height- 1.778 m (5’10”)
General: Patient appears as stated age, well developed, and in no acute distress. The
patient is mild mannered, well spoken, and has no difficulty with any speech or
social interaction. The patient is appropriately dressed and appears to have good
hygiene. There are no abnormal olfactory or extracorpeal clues noted.
Skin: There are no rashes, eruptions, bruising, redness, swelling, dryness or lesions.
The hair is in appropriate distribution, smooth, and well kept. The nails reveal no
clubbing, merckes lines, beaus lines, thickening, pallor, or pitting.
Chest/Lungs: Inspection reveals no scars, lesions, masses, accessory muscle use or
asymmetrical chest wall movements. Patient has no pain upon palpation, 1:2
AP/lateral ratio, and symmetrical respiratory excursion. Auscultation reveals clear,
unlabored breath sounds in all lung fields and no adventitious sounds such as rales,
ronchi, or wheezes.
Cardiac: Inspection of precordium reveals no lifts, heaves or visible PMI. Palpation
reveals no lifts, heaves, or thrills. Auscultation reveals regular rate and rhythm, S1,
S2 and no murmurs, clicks, gallops or rubs.
Abdominal: Inspection of the abdomen reveals no striae, ascites, scars, visible
peristalsis, pulsations, or obvious masses. Auscultation reveals no bruits of the
abdominal aorta, renal, external iliac, or femoral arteries. Bowel sounds are heard in
all four quadrants or normal quality and equal intensity. Percussion reveals no
hepatosplenomegaly, tenderness, or masses. The bladder was unable to be
percussed. Palpation reveals no tenderness, masses, hepatosplenomegaly, or
enlargement of the abdominal aorta. The kidneys were unable to be trapped. The
patient had no CVA tenderness. A rectal examination reveals appropriate sphincter
tone, no nodules or enlargement of the prostate, no bogginess or tenderness of the
prostate, and heme negative stool.
Genitourinary: Inspection reveals no redness, swelling, masses, or lesions of the
penile shaft, glands, scrotum or testicles. There is no redness, lesions, or discharge
noted at the urethra.
Urinalysis:
Component
Color
Clarity
Glucose
Bilirubin
Ketone
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Esterase
Ictotest
WBC
RBC
Value
Red
Cloudy
Negative
Small
Negative
1.010
Large
5.5
100
Normal
Negative
Large
Positive
20-29
20-29
A:
Diagnosis: Urinary tract infection
Differential Diagnosis: Renal lithiasis, GU malignancy, BPH, Intrinsic renal disease
like ATN, Glomerulonephritis
P:
Pending Labs: CBC w/ differentiation, CMP
Pending Imaging: None
Treatment: Cipro 250 mg PO BID x’s 7 days
Patient Education: Patient is told to continue his current medications, and to take
the full course of the antibiotic prescribed above. Patient is educated on possibility
of tendon rupture with the above antibiotic, and is told to follow up with a provider
immediately if he develops any tendon pain. Patient is told to stay well hydrated by
drinking 60-72 fluid ounces of water a day, and to self-monitor each void and pay
particular attention to when the hematuria begins and ends in his stream. Patient
was educated on possibility of the above differential diagnoses, and the importance
of follow up with his PCP and Urologist. Patient understood the treatment plan, and
had no further questions or concerns.
Referrals/Consults: Patient given a phone number to call local Urologist Dr. ***
***** and set up an appointment within 5-7 days. Their office was called to send
patient information with patient’s verbal and written consent.
Provider Notes: Patient was diagnosed with a UTI in the absence of any bacteria
noted on the initial UA. The abnormal protein levels may be falsely elevated due to
the amount of RBC in the urine. The amount of RBC in the urine does not correlate
with the severity of any disease process. The patient’s hematuria and proteinuria
should continue to be monitored by his PCP and Urologist to exclude the possibility
of other origins including renal parenchyma disease, glomerular disease,
malignancy or the GU tract, or renal lithiasis. Urologist may want to perform
cystoscopy sooner than later to increase chances of finding the origin of the
hematuria.
Follow Up: Patient is to follow up with his PCP within 3-5 days to coordinate
treatment with the Urologist, monitor hematuria and proteinuria, and evaluate for
hypertension. Patient is told to follow up at the ED if condition is worsening, patient
develops severe pain, is unable to void, becomes lethargic or confused, or develops a
fever or chills.
Elijah Hanna PA-S (9/4/12)