Genitourinary SOAP

Clinical SOAP Note: Acute Glomerulonephritis
Student’s Name:
Institutional Affiliation:

Clinical SOAP Note: Acute Glomerulonephritis
Mr. Dimples is a 48-year-old man residing in. He is self-referred to the institution and appears to be a reliable source for his history.
Subjective Component
Chief Complaint: ‘There is blood in my urine.’
History of presenting complaint:
Mr. Dimples first noticed blood in his urine two days ago. It was painless and continuous. He dismissed it and continued with his activities. His urine did not contain any blood the next three times he micturated. He noticed blood again the next day – which still was painless and continuous. He has never had a similar episode in his life. There was no identifiable aggravating or relieving factor. There was no oliguria, frequency, urgency, dysuria, any flank pain, nocturia, urinary incontinence, hesitancy, terminal dribbling, or urethral discharge.
Medical History:
As a child, Mr. Dimples was admitted for measles at the age of 6; chickenpox at age 10; malaria at age 12; and mumps at 13. He has no history of scarlet fever or rheumatic. As an adult, he has been admitted for food poisoning at age 30 due to consumption of stale rice. He was diagnosed with interstitial nephritis at age 35 after taking high-dose ampicillin to ward off a throat infection. The condition was treated successfully.
Surgical History:
Sutures for a laceration accrued by stepping on a rock while playing at age 15.
Medications:
He takes paracetamol to relieve headaches.

He seldom experiences the headaches, they are mild, happen once or twice a month, and mostly when he is working. He takes two 500mg tablets, which always relieve the pain.
Allergies:
He has no known food or drug allergies.
Family-Social History:
His father died at age 5 in a car accident. His mother is alive, aged 65, and suffers from diabetes and hypertension. He has one sibling who is alive, aged 42, and has mild hypertension.
He is married – his wife is aged 40 and has had no history of health complications. He has a daughter aged seven who is also healthy. There is no family history of kidney disease, cancer, anemia, mental illness, tuberculosis, or epilepsy.
He works as a gym instructor in _ school. His shifts are distributed evenly, and he loves his job. His wife works as a sales clerk in a firm located in the nearby town. They live in a two-bedroom apartment and use the water from the town’s pipeline system. He exercises a lot, primarily due to the nature of his occupation, and consumes a balanced diet for all three square meals.
Review of Systems:
General: Has had a fever in the last day, mild and was relieved with rest and taking paracetamol; no weight loss.
Cardiovascular: No dyspnea, orthopnea, paroxysmal nocturnal dyspnea, chest pain, palpitations. He has never had an EKG.
Respiratory: No cough, wheezing, sputum, hemoptysis. Never had a chest x-ray.
Gastrointestinal: Has a good appetite, no nausea, vomiting, dyspepsia; empties bowels once daily; no abdominal pain, diarrhea, jaundice, melena, hematochezia.
Nervous: No changes in mood, attention, speech, judgment; no headache, dizziness, seizures, syncope; no paralysis, numbness, tingling, tremors.
Objective Component
Mr. Dimples is tall and built. He appears well and has comfortable. He is neat, and his hair is well-groomed. He responds well to questions.
Vital Signs:
Height 176cm. Weight 82kg. BMI 26.47 – (standard). BP 166/100 right arm, supine; 164/98 left arm, supine – (hypertensive). Heart rate 106 b.p.m. – (high). Respiratory rate 19 breaths/minute – (normal). Temperature (oral) – 98.6 Fahrenheit degrees – (normal).

Physical Examination:
Hands and Arms: No leukonychia, Muehrcke’s lines visible, digital and palmar pallor, no cyanosis. No scars on arms, no bruises, no excoriations, no loss of sensory or motor function.
Thorax: Thorax moves symmetrically while breathing, good excursion, lungs resonant, vesicular breath sounds with no additional sounds, diaphragm descent 3.5 cm during inspiration.
Cardiovascular: jugular venous pressure 1.2 cm above the sternal angle with head-of-bed tilted at 30°. Carotid upstrokes brisk, no bruits. Apical beat distinct and tapping, not palpable in the 5th intercostal space, 7cm lateral to the midsternal line. Good S1, S2; no S3 or S4. Low-pitched mid-systolic murmur in the 2nd right intercostal space does not radiate to the neck. No diastolic murmurs.
Neck: Neck is supple. Trachea is in the midline. Thyroid isthmus not palpable, lobes not felt. No lymphadenopathy.
Abdomen: No visible distension. Symmetric. No scars or visible skin lesions. No tenderness. No masses. Navel folded inwards. Liver span 8 cm in the right mid-clavicular line, palpable 1.3cm below the right costal margin. Spleen and kidneys are not palpable. No costovertebral angle tenderness.
Genitalia: No external lesions on genitalia. No scrotal enlargement. No genital or adnexal tenderness.
Laboratory Findings:
Urine dipstick: Affirmation of hematuria.
24-hour urine collection: Mild proteinuria (2.7g/day). Urine contains white cells and red cell casts.
Renal ultrasound: Bilateral renal enlargement.
Assessment Component
Significant Health Concerns:
The diffuse renal enlargement coupled with the gross hematuria point towards kidney damage. The continual micturition indicates that kidney function has not been entirely disrupted. The medical professional should aim towards uncovering the underlying cause of the condition and immediate restoration of kidney function (Malvinder, 2017). The condition is most likely acute since the patient has few risk factors for the development of chronic conditions and the mild hematuria.
Differential diagnoses:
The differential diagnoses for the condition are (Vernon, Hall, & Fremeaux-Bacchi, 2012):
Acute glomerulonephritis
Idiopathic hematuria.
Familial nephritis.
Trauma to kidney parenchyma.
Anaphylactoid purpura with nephritis.
Priorities:
Restoration of renal function.
Investigation of possible underlying causes.
Administration of appropriate medication.
Adjustment of diet and physical activity.
Long-term monitoring of the outcome.
ICD 9 Code: Code 580
CPT Code: N05.5
Plan Component
Diagnostic Interventions:
The condition is confirmed by the presence of red cell casts in the urine, which are pathognomonic for acute glomerulonephritis. The bilateral swelling of the kidneys represents the edema which has developed due to the condition (Rodriquez-Iturbe & Haas, 2016). Serologic analysis of anti-GBM and antineutrophil cytoplasmic antibodies could be performed to categorize the condition – though not entirely necessary.
Therapeutic Interventions:
Supportive Care:
Admit to hospital.
Monitor vital signs closely and adopt necessary interventions based on their fluctuations. Elevated blood pressure is usually the most immediate concern and is managed using medication.
Medication:
Loop diuretics e.g. furosemide to control edema and hypertension.
Vasodilators e.g. sodium nitroprusside, hydralazine to control severe hypertension.
In case of severe acute glomerulonephritis, administer high-dose prednisone and cyclophosphamide.
Penicillin after investigation and found to have an underlying bacterial infection.
Diet and Physical Activity:
Restrict sodium and fluids in the diet to relieve edema.
Adequate bed rest until edema and glomerular inflammation subside.
Expected Outcomes:
Acute glomerulonephritis is an easily treatable condition – after provision of the necessary treatment, the glomerulus heals quickly (Watnick & Dirkx, 2017). The kidney function is restored, and the patient can be discharged within a few days.

Consultation:
The patient need not be referred to a specialist for his condition.Health Education:
The patient shall be informed to continue eating a healthy diet and to limit his salt consumption.
Disposition and Health Promotion:
Mr. Dimples should be asked to monitor his urine closely for the next few weeks and report to the hospital if he spotted blood again. He shall also be asked to make a scheduled visit every four weeks for the next six months for long-term monitoring of the development of any chronic conditions.
Ethical, Legal, and Geriatric Considerations:
The patient shall be treated individually, and his symptoms shall not be shared with anyone else without their permission. He shall be informed of his right to refuse any treatment offered, and informed consent shall be derived for all the adopted interventions. Since he is not elderly, Mr. Dimples is unlikely to suffer from any chronic sequelae.

References
Malvinder, S. P. (2017). Acute Glomerulonephritis Treatment and Management. Medscape. Retrieved from https://emedicine.medscape.com/article/239278-treatment#d1
Rodriguez-Iturbe, B., Haas, M. (2016). Post-Streptococcal Glomerulonephritis. In: Ferretti, J.J., Stevens, D.L., Fischetti, V.A. (editors). Streptococcus pyogenes: Basic Biology to Clinical Manifestations. Oklahoma City (OK): University of Oklahoma Health Sciences Center.
Vernon, K. A., Hall, A. E., & Fremeaux-Bacchi, V. (2012). Acute Presentation and Persistent Glomerulonephritis Following Streptococcal Infection in A Patient with Heterozygous Complement Factor H–Related Protein 5 Deficiency. American Journal of Kidney Diseases, 60(1), 121–125.
Watnick, S., & Dirkx, T. (2017). Kidney disease. In: Papadakis, M. A., & McPhee, S. J. (eds.). Current Medical Diagnosis and Treatment. New York: McGraw Hill Education.