The Approach to The Patient with Haematuria Discussion

The Approach to The Patient with Haematuria Discussion

Focused SOAP Note

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Patient Information:

Initials: R.B

Age: 95

Sex: Male

Race: White

S (subjective)

CC: “My urine is really red.”

HPI: R.B., a 95-year-old caucasian male, was brought by his son with concerns regarding the appearance of his urine. Upon using the restroom and observing the vibrant red coloration, he became aware of this change for the first time. The onset of this symptom occurred approximately two days ago suddenly. According to R.B., his urine consistently has a uniformly bright red hue without any observable clots or particles. No accompanying signs or symptoms exist, such as pain during urination, urgency, or discomfort. R.B. also mentions that there is no specific activity or event linked to the timing of this occurrence; nevertheless, it has remained consistent over the past two days. Regarding exacerbating or alleviating factors, R.B. has not identified any particular activities that cause an aggravation or bring relief from these symptoms. R.B. rates his level of concern as seven on a scale of 1 to 10 because this change’s sudden and unfamiliar nature is unsettling to him. The Approach to The Patient with Haematuria Discussion

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Current Medications:

Tamsulosin 0.4 mcg is prescribed as two capsules to be taken daily to manage benign prostatic hyperplasia and improve urinary flow. The patient has been regularly using this medication for three years.
Aspirin 325 mg is administered daily as an anticoagulant to prevent stroke due to the patient’s medical history involving ischemic CVA. This medication has been part of the patient’s regimen for five years.
Atorvastatin 10 mg daily provides cholesterol control and cardiovascular support. Its prescription was initiated four years ago after routine laboratory tests revealed elevated cholesterol levels.
Donepezil 10 mg is orally consumed once at night to alleviate cognitive symptoms associated with vascular dementia, initiated approximately two years ago.
Metoprolol 25-mg in half-tablet doses every twelve hours as a beta-blocker for managing hypertension and safeguarding cardiac health post-heart attack diagnosis in 2019.
Acetaminophen 500 mg: 1 tablet BID for arthritis pain and occasional headaches. OTC, used as needed.

Allergies:

Penicillin causes the patient hives, described as raised, itchy welts on the skin.

No known food or environmental allergies

PMHx:

Immunization status: Flu shot received annually, last tetanus shot in 2015.

Past major illnesses: ischemic CVA resulting in hemiplegia and hemiparesis, vascular dementia, and atrial fibrillation (12/2019), DVT on the lower extremity, gross hematuria

Surgeries: Prostate surgery for malignant neoplasm six years ago.

Soc and Substance Hx:

Occupation: Retired school teacher
Hobbies: They enjoy reading and engaging in gardening activities, although these hobbies are somewhat limited due to their hemiplegia condition.
Family status: a widower with two children.
Tobacco use: A previous smoker for three decades before quitting 25 years ago.
Alcohol consumption habits: Occasionally indulges in a single glass of wine without any past instances of excessive alcohol intake.
Health promotion Question: Regularly utilizes seat belts when traveling, ensures the presence of smoke detectors within their living space at the SNF, and refrains from using cell phones during transportation.

Fam Hx

– Father: Passed away due to myocardial infarction in his 70s.

– Mother: Lived till 90, passed due to natural causes.

– Siblings: One brother who passed from complications of diabetes in his late 80s.

– Children: Two children, both alive and healthy.

– Grandchildren: Three grandchildren, no significant health issues mentioned.

Surgical Hx: Prostrate surgery

Mental Hx: – Diagnosed with vascular dementia, currently managed with Donepezil.

– No history or current concerns of anxiety, depression, self-harm practices, or suicidal or homicidal ideation.

Violence Hx: no known issues about safety (personal, home, community, sexual (current and historical).

Reproductive Hx: Widowed and did not mention any issues or concerns related to sexual health

ROS:

GENERAL: Reports no unintentional weight loss, no chills or fever, some fatigue likely related to age and existing conditions, and no recent changes in overall strength or energy.

HEAD: Denies any head trauma frequent or new headaches.

EENT (eyes, ears, nose, and throat):

Eyes: No complaints of visual changes blurred or double vision. No yellowing of sclera. No history of cataracts or glaucoma.

Ears: No complaints of hearing loss or ringing in the ears.

Nose: No recent episodes of epistaxis, no congestion, or rhinorrhea.

Throat: No sore throat, hoarseness, or difficulty swallowing.

SKIN: Skin is intact, no rash, no itching, no recent changes in moles or skin lesions.

CARDIOVASCULAR: No new chest pain or discomfort. Denies palpitations. No known edema.

RESPIRATORY: No complaints of shortness of breath or cough. No history of asthma or COPD.

GASTROINTESTINAL: The appetite is good. Denies nausea, vomiting, diarrhea, or constipation. No blood in the stool or black tarry stools.

GENITOURINARY: Main complaint of red-colored urine (hematuria). Denies burning on urination or increased frequency.

NEUROLOGICAL: History of ischemic CVA, resulting in R-sided hemiplegia. No recent episodes of dizziness, syncope, seizures, or tremors. No changes in bowel or bladder control.

MUSCULOSKELETAL: Reports occasional joint pain, especially in the mornings. No back pain, muscle pain, or recent injuries.

HEMATOLOGIC: Labs indicate potential anemia. No known bleeding disorders or easy bruising.

LYMPHATICS: Denies enlarged lymph nodes or any known history of lymphedema.

PSYCHIATRIC: Diagnosed with vascular dementia. Denies feelings of depression, anxiety, or other mood changes.

ENDOCRINOLOGIC: Denies excessive thirst (polydipsia) or excessive urination (polyuria). No known history of diabetes or thyroid disease.

REPRODUCTIVE: Aged 95, no recent sexual activity reported. No known concerns with reproductive health.

ALLERGIES: Allergic to Penicillin, which causes hives. There is no history of asthma, seasonal allergies, or other known drug allergies. The Approach to The Patient with Haematuria Discussion

O (Objective)

Physical Exam:

VITAL SIGNS:

B.P.: 122/70 mmHg Heart Rate: 66 bpm, regular rhythm, Temperature: 98.0°F, Respiratory Rate: 18 breaths/min, Oxygen Saturation: 98% on room air

GENERAL: The elderly patient is alert and oriented x3, appears his stated age, and is in no acute distress. Given his cognitive communication deficit, he is calm, cooperative during the examination, and communicates clearly.

HEAD: The skull is normocephalic and atraumatic. Hair is gray and evenly distributed without signs of alopecia. No scalp tenderness or masses were palpated.

EENT:

Eyes: Pupils are equal, round, and reactive to light. Conjunctivae are pink and moist without pallor or icterus. No nystagmus or exophthalmos was noted.

Ears: External ears are symmetrical without masses or lesions. No drainage was noted from either ear.

Nose: No nasal discharge, septum midline.

Throat: The Oropharynx is moist without erythema or exudate.

NECK: Supple, with full range of motion. No jugular venous distension. Trachea midline. No palpable lymphadenopathy or masses.

CARDIOVASCULAR: Heart rhythm is regular; no murmurs or gallops are heard on auscultation. Pulses are 2+ and symmetrical in all extremities. Capillary refill is less than 2 seconds in all digits.

RESPIRATORY: Lungs clear to auscultation bilaterally, with symmetric chest expansion. No wheezes, rhonchi, or crackles were heard.

GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended. Bowel sounds are present and normoactive in all four quadrants. No hepatosplenomegaly upon palpation.

GENITOURINARY: The external genitalia appear to be age-appropriate. The absence of the prostate on rectal examination is consistent with his prior prostatectomy for prostate cancer. There are no signs of inflammation, nodules, or masses at the surgical site.

MUSCULOSKELETAL: Demonstrates right-sided weakness as per his previous ischemic CVA. Full range of motion in left extremities. No joint deformities were noted.

NEUROLOGICAL: Cranial nerves II-XII are grossly intact. Demonstrates right-sided facial droop. Muscle strength is 3/5 on the right side and 5/5 on the left.

SKIN: Warm and dry to the touch. No rashes, ulcers, or notable lesions. Good skin turgor. The Approach to The Patient with Haematuria Discussion

Diagnostic Results:

Complete Blood Count (CBC):

RBC: 3.53 (L), suggesting potential anemia.

Hemoglobin: 10.2 (L)

Urinalysis:

Color: Red, indicating the presence of blood.

Specific Gravity: 1.020

Blood: Large amounts present, confirming hematuria.

P.H.: 7.0

Leukocytes: Small amounts.

Nitrites: Positive, which can indicate a urinary tract infection.

Microscopic Analysis of the Urine:

WBC UA: 42 (H), suggesting inflammation or infection.

RBC UA: >900 (H) confirming gross hematuria.

Epithelial cells: 2

A (Assessment)

Differential Diagnoses:

Urinary Tract Infection (UTI): A urinary tract infection is a condition that affects the bladder, urethra, kidneys, and ureters, among other parts of the urinary system (Fath-Bayati et al., 2023). UTIs can cause painful urination (dysuria), frequent urinal urges (urinary frequency), and urgency (Kornfält Isberg et al., 2020). In severe cases, gross hematuria is visible blood in the urine, mainly when it affects the kidneys (upper urinary tract). UTIs are especially dangerous for older adults because they can cause systemic symptoms and progress to urosepsis, a potentially fatal condition. In R.B.’s case, elevated white blood cells in the urine and positive nitrites point to a urinary tract bacterial infection. Given R.B.’s age and clinical presentation, a UTI diagnosis is critical.

Bladder or Kidney Stones (Urolithiasis): “Urolithiasis” refers to solid mineral and salt deposits in the urinary system, including kidney and bladder stones. Among other areas of the urinary tract, they can develop in the kidneys, ureters, bladder, or urethra (Malhotra et al., 2022). The severe hematuria observed in R.B.’s case may be due to stones, which can irritate and harm the lining of the urinary tract and result in blood appearing in the urine. These stones can cause mild discomfort or excruciating pain depending on size and location. Given R.B.’s age group, there is an increased risk of stone formation because of decreased fluid intake, underlying medical conditions, and medication side effects. Intervention may be required, either through fragmentation or surgical removal, if a stone prevents normal urine flow or causes persistent symptoms (Etienne Xavier Keller et al., 2021).

Bladder Cancer: Gross hematuria, characterized by blood in the urine, is a prevalent indication of bladder cancer (Liang et al., 2022). It is essential to thoroughly investigate and eliminate other potential causes, such as malignancies affecting the bladder or other parts of the urinary tract, particularly considering this patient’s age and previous diagnosis of prostate cancer. The American Urological Association states that individuals with risk factors like advanced age and smoking history should be especially vigilant in ruling out bladder cancer when experiencing gross hematuria (Willis and Tewelde, 2019). The Approach to The Patient with Haematuria Discussion

P (plan)

Diagnostic Studies: The urine culture and sensitivity results are being awaited to determine the appropriate antibiotic therapy.

Therapeutic Interventions: Commence empirical antibiotic therapy, considering the patient’s penicillin allergy. A suitable option may be Ciprofloxacin 500 mg, taken orally twice daily for seven days. Adjust the antibiotic choice based on the culture and sensitivity testing results.

Education: Educate R.B. on the significance of completing the entire course of antibiotics, even if symptoms improve. Provide instructions regarding indicators suggestive of a worsening UTI, such as fever, flank pain, or increased confusion.

Follow-up: Schedule a follow-up appointment in one week to ensure resolution of symptoms and adequate treatment response to address infection.

Referrals: Consider referring R.B. to a urologist for further evaluation, given their medical history and current symptomatology requiring thorough assessment.

Disposition: Continue monitoring at the skilled nursing facility with close observation for any alterations in mental status or vital signs.

Reflection

This case exemplified the complex nature of caring for elderly individuals. The evaluation of R.B.’s presentation went beyond surface-level symptoms and delved into the underlying factors contributing to their condition. One key realization was understanding the interconnectedness of different health issues, particularly in older adults, emphasizing the need to investigate any symptom thoroughly and not make assumptions based solely on its appearance.

Integrating health promotion and disease prevention into care is vital, particularly for elderly patients. Considering R.B.’s age and Caucasian ethnicity, he belongs to a demographic that faces higher susceptibility to urinary tract infections, notably in post-hospital care settings. Given his medical history and background, taking proactive measures to prevent common geriatric illnesses is crucial. This includes promoting good personal hygiene, encouraging adequate fluid intake, and potentially discussing cranberry supplements or juice, as some studies suggest their potential benefits in UTI prevention. It’s essential also to consider socio-economic and cultural factors that have significant influence but were not explicitly mentioned for R.B. Gaining insights into his background, lifestyle habits, and daily routines can inform tailored preventive strategies specifically designed for him. Regular check-ups, age-appropriate screenings, and consistent family engagement can enhance overall health outcomes for R.B. himself and other individuals in similar situations. The Approach to The Patient with Haematuria Discussion

References

Etienne Xavier Keller, Vincent De Coninck, Olivier Traxer, Asaf Shvero, Kleinmann, N., Hubosky, S. G., Steeve Doizi, Hardacker, T., Bagley, D. H., & Sonzogni-Cella, M. (2021). Stones. Springer EBooks, 105–154. https://doi.org/10.1007/978-3-030-82351-1_5

Fath-Bayati, L., Namdari, H., Parvizpour, F., Awad, I., Ghiasi, M., Sefat, F., & Arabpour, Z. (2023, January 1). Chapter 10 – Encapsulation in the Urinary System (F. Sefat, G. Farzi, & M. Mozafari, Eds.). ScienceDirect; Woodhead Publishing. https://www.sciencedirect.com/science/article/abs/pii/B9780128243459000210

Kornfält Isberg, H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2020). Uncomplicated Urinary Tract Infection in Primary Health Care: Presentation and Clinical Outcome. Infectious Diseases, 53(2), 94–101. https://doi.org/10.1080/23744235.2020.1834138

Liang, D., Xiang, Y., SONG, T., Zhou, G., & SHEN, T.-M. (2022). Diabetes Is a Risk Factor for the Prognosis of Patients with Bladder Cancer: a Meta-Analysis. Journal of Oncology, 2022, 1–7. https://doi.org/10.1155/2022/1997507

Malhotra, M., Tandon, P., Wadhwa, K., Melkani, I., Singh, A. P., & Singh, A. P. (2022). The Complex Pathophysiology of Urolithiasis (kidney stones) and the Effect of Combinational Drugs. Journal of Drug Delivery and Therapeutics, 12(5-S), 194–204. https://doi.org/10.22270/jddt.v12i5-S.5718

Willis, G. C., & Tewelde, S. Z. (2019). The Approach to the Patient with Hematuria. Emergency Medicine Clinics of North America, 37(4), 755–769.

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SOAP Notes for UTI

What additional subjective data are you seeking?

When a patient presents with symptoms similar to R.B.’s, it is necessary to collect additional subjective data to ensure comprehensive care and accurate diagnosis.

Inquire about any accompanying symptoms that may be present alongside the bright red urine, such as pain or discomfort during urination, urgency, frequency, or incontinence. Additionally, ascertain if there have been any observations of blood clots in the urine.
Determine the exact timeline for when the change in urine color was first noticed. Is it consistently present over the past two days? Does its intensity fluctuate?
Explore whether there have been recent experiences of fatigue, dizziness, or shortness of breath that could potentially indicate anemia-related issues.
Enquire about any dietary modifications involving foods like beets or carrots that might impact urine coloration and inquire into medication usage that could affect urine appearance.
Ascertain if there has been any history of recent trauma or medical procedures (e.g., catheterization) that may account for observed hematuria (Ingelfinger, 2021).

What additional objective data will you be assessing for?

During the abdominal examination, palpation and auscultation should be conducted on the abdomen with emphasis on evaluating for tenderness, masses, or distension in the kidneys and bladder (Yew et al., 2023). The genitourinary exam should include a physical assessment of the external structures to gather relevant information. To identify peripheral anemia, observe for signs such as pallor or cyanosis during the peripheral examination. Carefully evaluate edema in the lower extremities, which may indicate potential kidney-related complications. The Approach to The Patient with Haematuria Discussion

What medical history would you obtain from the patient? List at least three.

The historical background of kidney disease: It is valuable to gather information on any familial or personal history concerning kidney diseases, as this can offer significant insights (Brown et al., 2021).
Coagulation and hemorrhagic disorders: It is necessary to ascertain whether there is a medical history associated with clotting or bleeding disorders in light of the symptoms exhibited and the medication list provided.
Assessing risk exposure levels: Examining potential occupational or environmental exposures linked to hazardous chemicals or substances that may impact the renal system is essential.

What tests will you order? Describe at least four lab tests.

The Complete Blood Count is utilized to assess the severity and type of anemia, given explicitly to hemoglobin levels, hematocrit levels, and platelet count.
Kidney Function Tests are conducted, measuring Serum Creatinine and BUN levels to evaluate renal function.
Urinary Cytology involves examining urine under a microscope for atypical cells that could indicate cancer, aiding in diagnosis.
Given the patient’s history of deep vein thrombosis and use of aspirin, it is crucial to conduct a Blood Coagulation Profile test to assess clotting factors and platelet function (Kim et al., 2023).

What are the differential diagnoses that you are considering? Describe two.

Urinary Tract Infection (UTI):

A urinary tract infection is a condition that impacts different parts of the urinary system, like the bladder, urethra, kidneys, and ureters (Fath-Bayati et al., 2023). In R.B.’s case, elevated white blood cells in the urine and positive nitrites indicate a potential bacterial infection in the urinary tract. UTIs can present with various symptoms, including painful urination (dysuria), frequent urge to urinate (urinary frequency), and urgency (Kornfält Isberg et al., 2020). In severe cases or when it affects the kidneys (upper urinary tract), there may be visible blood in urine called gross hematuria. For elderly individuals specifically, UTIs are concerning as they can lead to systemic symptoms and potentially progress into urosepsis—a life-threatening condition. Given R.B.’s age and clinical presentation, immediate attention is necessary, considering a possible UTI diagnosis. The Approach to The Patient with Haematuria Discussion

Bladder or Kidney Stones:

Urolithiasis, a term for the solid mineral and salt formations in the urinary system, includes kidney and bladder stones. These stones may develop in the kidneys, ureters, bladder, or urethra, among other urinary tract areas (Malhotra et al., 2022). The gross hematuria observed in R.B.’s case may suggest the possibility of stones since they can cause irritation and damage to the lining of the urinary tract, resulting in blood appearing within the urine. The pain level experienced due to these stones can vary from mild discomfort to intense agony, depending on their size and location. Given R.B.’s age group, there is an increased likelihood of stone formation due to various factors, including reduced fluid intake, co-existing medical conditions or adverse effects caused by specific medications. If a stone obstructs normal urine flow or leads to persistent symptoms, it might necessitate intervention through fragmentation or surgical removal (Etienne Xavier Keller et al., 2021).

What is your plan of care for this anemic patient? List at least two diagnostic tests you will order to evaluate the cause of her condition.

Given R.B.’s age, medical history, and symptoms, careful consideration and timely action are essential.

Diagnostic Tests:

Cystoscopy: A procedure using a cystoscope to view the inside of the bladder, assisting in determining the cause of the hematuria (Cardozo & Staskin, 2023).
Renal Ultrasound: A non-invasive procedure to check for kidney or bladder abnormalities, masses, or stones.

Treatment:

For suspected UTIs, begin empiric antibiotic therapy suitable for elderly patients and adjust based on the C&S results.

Monitor Hemoglobin and RBC levels regularly. If anemia worsens or persists, consider a referral to hematology.

Patient Education:

– Emphasize the importance of hydration.

– Discuss potential side effects of medications and what to monitor.

– Importance of regular follow-ups, especially with his age and his medications. The Approach to The Patient with Haematuria Discussion

References

Brown, E. A., Zhao, J., McCullough, K., Fuller, D. S., Figueiredo, A. E., Bieber, B., Finkelstein, F. O., Shen, J., Kanjanabuch, T., Kawanishi, H., Pisoni, R. L., Perl, J., Jassal, V., Fukasawa, M., Wilson, S., Cheawchanwattana, A., Fang, W., & Ljungman, S. (2021). Burden of kidney disease, health-related quality of life, and employment among patients receiving peritoneal dialysis and in-center hemodialysis: Findings from the DOPPS program. American Journal of Kidney Diseases, 78(4), 489-500.e1. https://doi.org/10.1053/j.ajkd.2021.02.327

Cardozo, L., & Staskin, D. (2023). Textbook of female urology and urogynecology: Clinical perspectives. In Google Books. CRC Press. https://books.google.co.ke/books?hl=en&lr=&id=xnPAEAAAQBAJ&oi=fnd&pg=PA373&dq=A+procedure+using+a+cystoscope+to+view+the+inside+of+the+bladde

Fath-Bayati, L., Namdari, H., Parvizpour, F., Awad, I., Ghiasi, M., Sefat, F., & Arabpour, Z. (2023, January 1). Chapter 10 – encapsulation in the urinary system (F. Sefat, G. Farzi, & M. Mozafari, Eds.). ScienceDirect; Woodhead Publishing. https://www.sciencedirect.com/science/article/abs/pii/B9780128243459000210

Ingelfinger, J. R. (2021). Hematuria in adults. New England Journal of Medicine, 385(2), 153–163. https://doi.org/10.1056/nejmra1604481

Kim, C., Jae Suk Chang, Lim, Y., Lim, D., & Ji Wan Kim. (2023). Safety of urgent surgery for the patients with proximal femur fracture treated with platelet aggregation inhibitors: a propensity-score matching analysis. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1007/s00068-023-02368-9

Kornfält Isberg, H., Hedin, K., Melander, E., Mölstad, S., & Beckman, A. (2020). Uncomplicated urinary tract infection in primary health care: presentation and clinical outcome. Infectious Diseases, 53(2), 94–101. https://doi.org/10.1080/23744235.2020.1834138

Malhotra, M., Tandon, P., Wadhwa, K., Melkani, I., Singh, A. P., & Singh, A. P. (2022). The complex pathophysiology of urolithiasis (kidney stones) and the effect of combinational drugs. Journal of Drug Delivery and Therapeutics, 12(5-S), 194–204. https://doi.org/10.22270/jddt.v12i5-S.5718

Yew, K. S., George, M. K., & Allred, H. B. (2023). Acute abdominal pain in adults: Evaluation and diagnosis. American Family Physician, 107(6), 585–596. https://www.aafp.org/pubs/afp/issues/2023/0600/acute-abdominal-pain-adults.html The Approach to The Patient with Haematuria Discussion