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OPIC: Urinary Tract Infection in Pregnancy
Subjective
State the patient's chief complaint, reason for visit and/or the problem for which you are providing follow-up.
The client is a married, 28-year-old Asian woman who is 37 weeks pregnant. This is her second pregnancy and her first child is alive and living at home with both parents and she has no history of miscarriage. The client's chief complaint concerns her increasing problems with urination.
All symptoms related to the problem are described using the following cue descriptive categories:
Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem).
The client presents with complaints of a constant need to urinate that causes a burning sensation. The client reports drinking cranberry juice in an effort to alleviate these symptoms but no other self remedies. The client denies tobacco, alcohol or illicit drug use.
Associated symptoms
Besides a burning sensation when urinating, the client also reports experienced pain in her pelvis and her urine appears cloudy.
3) Quality of all reported symptoms including the effect on the patient's lifestyle
The client's constant need to urinate has caused her to remain at home for the past several weeks. The client also reports trouble resting and sleeping due to her constant need to urinate.
4) Temporal factors (date of onset, frequency, duration, sequence of events)
The client reports having to urinate more than 20 times a day, and vomiting on occasion.
5) Location (localized or generalized? does it radiate?)
Besides pelvic pain, the client also reports experiencing occasional pain in her lower left back.
6) Sequelae (complications, impact on patient and/or significant other)
The client's self-restriction to home has adversely affected her social life, including her previously regular weekly restaurant outings with friends.
7) Severity of the symptoms
The client reports increasing urgency in urination and severity of burning sensation in recent weeks.
b. Pertinent...
Postnatal, Immunizations, Tests, Dental Care, Allergies, Accidents, Childhood illnesses, Operations, Hospitalizations.
The client denies experiencing these symptoms during her first pregnancy which was uneventful. The client reports having been hospitalized last year to have a broken ankle surgically reduced with a plate after falling in the kitchen on a wet tile floor.
c. Family History includes family members, family health history, social history to include, residence, financial situation, outside assistance, family interrelationships, school experiences that are relevant to the problem are stated.
The client has an associate's degree but is currently unemployed although she has worked as an administrative assistant in a law firm until having her first child 4 years previously. Her husband is employed full time as a stock broker, the family has full coverage health insurance and is financially secure. The client's parents are dead but she has two siblings (brother and sister) living in China.
d. The Review of Systems relevant to the chief complaint/presenting problem is included.
General: (-) fever, easy fatigability, chills; (+) weight gain of 5 lbs. in previous week.
Skin: (-) pallor, diaphoresis; (-) rash
HEENT: (-)…
References
Delzell, J. E. & Lefevre, M. L. (2000, February 1). Urinary tract infections during pregnancy. American Family Physician, 61(3), 713-720.
Ectopic pregnancy symptoms. (2016). Mayo Clinic. Retrieved from http://www.mayoclinic.org/ diseases-conditions/ectopic-pregnancy/basics/symptoms/con-20024262.
Evans, C. & Tippins, E. (2007). The foundations of emergency care. Maidenhead, England: Open University Press.
Feinbloom, R. I. (2009). Pregnancy, birth, and the early months: The thinking woman's guide. Cambridge, MA: Perseus Publishing.
Kidney pain causes. (2016). Mayo Clinic. Retrieved from http://www.mayoclinic.org/symptoms/ kidney-pain/basics/causes/sym-20050902.
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