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Annotated Soap Note - Assignment Example

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The patient complains of lower back flank pain that is limiting her to perform her normal tasks. Her greatest worry is that she noticed some blood in the urine. She describes the pain as…
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Annotated Soap Note

Social history: She denies taking alcohol or drugs but admits to smoking at least two cigarettes daily. She lives a very active life where she does a lot of walking activities. Her diet consists of high calories, fat, fruits, and vegetables.
From the information gathered, the patient is likely suffering from bladder infection. Flank pain is associated with renal and upper urinary tract illnesses. In addition, the pain is a sign of underlying illness which in this case is bladder infection (Lippincott & Wilkins, 2008). The illness is diagnosed through a clean-catch mid-stream urine stream specimen to perform culture and determine the presence of bacteria. Concentration that is more than 100,000 organisms per ml of urine rules out the diagnoses (Murray & Pizzorno, 2012).
The culture is repeated after seven to fourteen days after therapy to check if it has cleared (Schapiro, 2014). The treatment will include Norfloxacin (Noroxin) 400mg BID for three days (Tripathi, 2013). In addition, the patient is prescribed 100mg calcium C four times daily. It aids in making the urine more acidic that makes it unfavorable for bacterial growth. The best management of bladder infections is preventing the bacterial growth. To attain this, the patient is educated on how to limit the development of bacteria. It includes urinating completely and frequently. In addition, she should avoid keeping urine in the bladder for a long time. Moreover, she is advised on hygiene tips especially how to clean herself after bowel movement. She should perform it from front to back. Furthermore, she should avoid underwear that is from synthetic fabrics that has the tendency of confining moisture. She will be trained on the significance of taking sufficient fluid that is mostly six to eight glasses daily, as it eliminates toxins from the bladder (Schapiro, 2014).
The patient is also ... Read More
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