Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following: R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF) “My urine is really red.” On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below. Penicillin: Hives : Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID DNR Regular diet, pureed texture, honey-thickened liquids BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%  Weight:____ BMI:____ Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria RBC                         3.53 (L) Hemoglobin           10.2 (L) RBC, UA                                    >900 (H) (0-5/HPF) Epithelial cells, urine               2           (0-4 /HPF) Hyaline casts, UA                     0           (0-2 /LPF) Color Red Appearance (Urine)    Clear Ketones, UA                 Trace Specific gravity             1.020               (1.005-1.025) Blood, UA                     Large PH, Urine                      7.0       (5.0-8.0) Leukocytes                   Small C&S results were not available yet. Purchase the answer to view it

Focused SOAP Note Template:

R.B., a 95-year-old white male, presented to the clinic with a chief complaint of red-colored urine. The patient reports that the redness in his urine was noticed two days ago and has persisted since then. The patient’s son accompanied him and expressed concern regarding this symptom. The patient currently resides in a skilled nursing facility (SNF).

Vitals: Blood pressure (BP) is 122/70 mmHg, heart rate (HR) is 66 bpm, temperature is 98.0°F, respiratory rate (RR) is 18 breaths per minute, and pulse oximetry shows 98% oxygen saturation. The patient’s weight and BMI are unknown at this time.

Medical History:
1. Cognitive communication deficit
2. Pneumonitis due to inhalation of food and vomit
3. Dysphagia
4. R-side hemiplegia and hemiparesis from past ischemic cerebrovascular accident (CVA)
5. Moderate vascular dementia
6. Malignant neoplasm of the prostate
7. New-onset atrial fibrillation (12/2019)
8. Deep vein thrombosis (DVT) in the left lower extremity
9. Gross hematuria

The patient’s current medication regimen includes:
1. Tamsulosin 0.4 mcg, 2 capsules daily
2. Aspirin 325 mg daily
3. Atorvastatin 10 mg, 1 tablet daily
4. Donepezil 10 mg, 1 tablet orally every night
5. Metoprolol 25 mg, 0.5 mg tablet every 12 hours
6. Acetaminophen 500 mg, 1 tablet twice daily
Note: The presence of “DNR” indicates a do not resuscitate status.

Based on the patient’s presentation and objective findings, the following assessments can be made:
1. Hematuria: The patient’s complaint of red-colored urine along with the laboratory results (RBC >900 /HPF) indicates the presence of gross hematuria.
2. Anemia: The low hemoglobin level (10.2 g/dL) suggests the patient has anemia, which may be related to the underlying condition or malignancy.
3. Urinary tract infection (UTI): The presence of leukocytes in the urine (small) may indicate the possibility of a UTI, although culture and sensitivity results are not yet available.

1. Further evaluation: Pending results of the culture and sensitivity (C&S) test, additional diagnostic tests may be necessary to identify the cause of the hematuria. These tests may include imaging studies such as ultrasound or computed tomography (CT) scan, as well as a cystoscopy if indicated.
2. Consultation: Consider involving a urologist to assess the patient’s urinary tract and provide further management of the hematuria.
3. Address anemia: Depending on the etiology of the anemia, appropriate interventions may include iron supplementation, blood transfusions, or referral to a hematologist for further evaluation and management.
4. UTI management: Based on the results of the C&S, initiate appropriate antibiotic therapy to treat any identified urinary tract infection.
5. Symptomatic relief: Address the patient’s discomfort, if any, related to hematuria by providing appropriate analgesic medications.
6. Collaborative care: Communicate the findings and discuss the patient’s situation with the skilled nursing facility staff to ensure comprehensive management of the patient’s health needs.

The patient should be advised to monitor the color of his urine, and any changes or worsening symptoms should be reported to the healthcare provider promptly. Follow-up appointments should be scheduled for close monitoring and further evaluation of the hematological and urinary conditions.

Note: This focused SOAP note template provides a preliminary assessment and plan based on the given information. As the C&S results are not yet available, the final diagnosis and management plan may be modified accordingly.