SOAP Note

Subjective:

The patient is a 90-year-old female presenting with complaints of neck pain, urinary frequency, and a chronic morning cough. She denies any recent injury or falls.

Objective:

• Vital signs and full physical examination are not provided, but the patient has tenderness on the left side of her neck and is able to move her neck.
• Laboratory results:
  • CBC: WBC 14.4, absolute monocytes 1.2
  • CMP: Glucose 215, Sodium 133, BUN 28, Creatinine 1.20, eGFR 43
  • CRP: 23
  • Hgb A1C: 6.1
  • Urinalysis: Moderate blood, protein 100, leukocyte esterase large, WBC >50, bacteria 11-20
• Chest X-ray: Shows sternotomy, cardiac enlargement, normal pulmonary vascularity, linear fibrosis in both lower lungs, mild chronic elevation of the right hemidiaphragm, scattered degenerative changes, osteopenia, and no acute fracture or bone mass.

Assessment:

The differential diagnosis for this patient can be categorized as follows:

• Single Most Likely Diagnosis:
  • Urinary Tract Infection (UTI): The patient's symptoms of urinary frequency, moderate blood in urine, proteinuria, and the presence of leukocyte esterase, WBC >50, and bacteria in the urinalysis strongly suggest a UTI. The elevated WBC count and CRP level also support an infectious process.
• Other Likely Diagnoses:
  • Pyelonephritis: Given the patient's age and the presence of bacteria in the urine, pyelonephritis is a possible complication of the UTI, especially if the infection has ascended to the kidneys.
  • Chronic Kidney Disease (CKD): The patient's eGFR of 43 indicates impaired renal function, suggesting CKD. This could be a contributing factor to her urinary symptoms and could be exacerbated by a UTI.
  • Diabetes Mellitus: Although the Hgb A1C is 6.1, which is near the upper limit of normal, the glucose level is elevated at 215, suggesting possible impaired glucose regulation or undiagnosed diabetes, which could predispose her to infections like UTIs.
• Do Not Miss Diagnoses:
  • Sepsis: Although the patient does not display classic signs of sepsis, her elevated WBC count and CRP, along with the presence of a UTI, necessitate consideration of this potentially life-threatening condition, especially in an elderly patient.
  • Spinal Epidural Abscess: Given the neck pain and tenderness, although the patient denies injury or falls, this condition could be a rare but serious cause of her symptoms, especially if there's an underlying infection.
• Rare Diagnoses:
  • Tuberculosis (TB): The chronic cough and the presence of linear fibrosis in both lower lungs on the chest X-ray could suggest pulmonary TB, although this would be less likely given the acute presentation of urinary symptoms.
  • Malignancy: The presence of moderate blood in the urine could also suggest a urinary tract malignancy, although this would be less likely without other supporting symptoms or findings.

Plan:

The plan would involve treating the most likely diagnosis (UTI) with appropriate antibiotics, managing any complications or related conditions (such as CKD or potential diabetes), and further investigating the less likely but potentially serious conditions (such as sepsis or spinal epidural abscess) with additional tests or imaging as necessary. Monitoring of the patient's condition and adjustment of the treatment plan based on response and further diagnostic findings would be crucial.