SOAP Note
S - Subjective:
- 27-year-old female presenting with nausea, vomiting, diarrhea, weight loss, dizziness, and frequent urination.
- Confirmed pregnancy at 7 weeks gestation.
- Denies abdominal pain, blood in stool, dysuria, burning with urination, fever, and chills.
O - Objective:
- CBC unremarkable.
- CMP shows CO2 18, otherwise unremarkable.
- Urinalysis: proteinuria 30, leukocyte esterase trace, WBC 6-10, RBC 3-5, moderate bacteria.
A - Assessment:
- Differential diagnosis for the patient's symptoms includes several possibilities, categorized below.
P - Plan:
- Further evaluation and management will depend on the differential diagnosis.
Differential Diagnosis
- Single Most Likely Diagnosis
- Urinary Tract Infection (UTI) in Pregnancy: The presence of moderate bacteria, proteinuria, and leukocyte esterase in the urine, along with symptoms of frequent urination, suggests a UTI. Pregnancy increases the risk of UTIs due to physiological changes.
- Other Likely Diagnoses
- Hyperemesis Gravidarum: Given the patient's pregnancy and symptoms of nausea, vomiting, and weight loss, hyperemesis gravidarum is a consideration, especially since it can lead to dehydration and electrolyte imbalances.
- Gastroenteritis: The onset of loose stools could indicate a gastrointestinal infection, which might be viral or bacterial in nature.
- Do Not Miss Diagnoses
- Preeclampsia: Although less likely at 7 weeks gestation, preeclampsia can present with proteinuria and should be considered, especially with the patient's symptoms of dizziness and weight loss.
- Diabetic Ketoacidosis (DKA): The patient's symptoms of frequent urination, nausea, and weight loss could also suggest DKA, particularly if she has undiagnosed diabetes. The low CO2 level on the CMP could indicate a metabolic acidosis.
- Rare Diagnoses
- Acute Kidney Injury: Although the urinalysis shows some abnormalities, acute kidney injury would be unusual without other significant symptoms or laboratory findings indicative of renal failure.
- Chronic Kidney Disease: Unlikely without a history of kidney disease, but the proteinuria and hematuria could prompt further investigation if other causes are ruled out.
Each diagnosis is considered based on the patient's symptoms, laboratory results, and the context of her pregnancy. The plan would involve further testing and management based on the most likely diagnoses, with careful consideration of the "do not miss" diagnoses due to their potential severity.