Case Study Analysis Exampl with SOAP Note

Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Does the subjective and objective information support the assessment? Why or why not?
• Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
• Please note this is an analysis of a soap note.  Please make sure to go directly by the grading rubric.  Do not deviate from the grading rubric!  Please answer all requirements of the grading rubric.

Genitourinary Assessment SOAP Note

• CC: Increased frequency and pain with urination
• HPI:
  • T.S. is a 32-year-old woman who reports that for the past two days, she has had dysuria, frequency and urgency. He has not tried anything to help with the discomfort. Has had this symptom years ago. She is sexually active and has a new partner for the past 3 months.
• Medical History:
• Surgical History:
• ·       Tonsillectomy in 2001
• ·       Appendectomy in 2020
• Review of Systems:
• ·       General: Denies weight change, positive for sleeping difficulty because e the flank pain. Feels warm.
• ·       Abdominal: Denies nausea and vomiting. No appetite
• Objective 
• VSS T = 37.3°C, P = 102/min, RR = 16/min, and BP = 116/74 mm Hg.
• Pelvic Exam:
• ·       mild tenderness to palpation in the suprapubic area
• · Bimanual pelvic examination reveals a normal-sized uterus and adnexae
• ·       no adnexal tenderness.
• ·       No vaginal discharge is noted.
• ·       The cervix appears normal.
• ·       Diagnostics: Urinalysis, STI testing, Pap smear
• Assessment:
• ·       UTI
• ·       STI
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
• The Lab Assignment
• Using evidence-based resources from your search, answer the following questions and support your answers using current evidence from the literature.
• ·       Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• ·       Analyze the objective portion of the note. List additional information that should be included in the documentation.
• ·       Is the assessment supported by subjective and objective information? Why or why not?
• ·       Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
• ·       Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Rubric attached

Case Study Analysis Example 32-year-old woman -solution

Introduction

Acute kidney transplant rejection is a result of the body’s immune system trying to protect itself from anything foreign. The condition develops in 10-20% of kidney transplantations and manifests in line with the reduced functionality of the kidney. Rejection occurs due to genetic disparity, which is countered through immunosuppressants initiated during the transplantation process or prescribed after the process.

In the case of patients with symptoms of acute kidney transplant rejection, it is imperative to examine the manifestation of the disease, trace and show the genes linked to the development of the disease, and analyze immunosuppression and its impact on the patient’s body.(Genitourinary Assessment Essay Example)

Symptoms Presented by the Patient

Weight gain associated with high temperatures, fatigue, and decreased urine output shows rejection of the new kidney by the body (Cashion et al., 2014). Post-transplant weight gain is associated with using immunosuppressive medications that protect the newly implanted kidney, along with diet changes and insufficient physical activity.

The immune system identifies the new kidney as a foreign object and attacks it, leading to its reduced functionality. (Genitourinary Assessment Essay Example).

The subsequent manifestations include fatigue, low urinal output, and a fever above 101 degrees Fahrenheit. Moreover, acute rejection manifests within a year of a transplant, with the risk being the highest within the first three months after the transplant.

Kidney biopsy, repeated blood work, and renal ultrasound tests could help diagnose acute kidney rejection while a high dosage of the anti-rejection drug is used to manage and treat the rejection (Justiz, Waheed, Fan, Misra, & Fitzgerald, 2018).

Genetic Disparity

The development of acute kidney transplant rejection is because of class I and class II HLA gene disparity between the donor and the receptor. Besides the matching of the ABO blood group to bar the interaction of A and B on the endothelium, Increased expression of HLA class I and HLA class II antigens in inflamed grafts paired with early infiltration of CD8+ cells led to the rejection (Starzl, 2011).

Further, rejection can result from genetic disparity, allowing the immune system to see MHC class I and II as foreign to the body.

Antigen Presenting Cells (APC) trigger CD4+ to react to the graft kidney by producing cytokines that further trigger the immune system to attack and destroy the new organ as foreign within days.

Immunosuppression and Effects on the Patient’s Body

To limit the attacks and rejection, immunosuppression suppresses the immune system and its ability to attack organs or infections it deems foreign. Post-transplantation, suppression by decreasing the activity of the immune system by targeting T-cell activation by either induction therapy during the transplant and up to 10 days after the transplant or by drug therapy post-transplantation.

Hence, agents such as monoclonal antibodies bind with CD3 to block T-cell activation and can be used in the initial induction therapy and the treatment of acute rejection (Naik & Shawar, 2020).

Immunosuppression agents Daclizumab, basiliximab, and polyclonal antibodies can also be used in the induction therapy stages to block IL-2 binding while also binding several sites on T-cells to block activation.

After the induction therapy approaches, immunosuppression shifts to long-term suppression and maintenance therapy, with the primary goals being to ensure survival by reducing drug toxicity and side effects as well as managing the risk of infections.

The anti-rejection drugs used by the patient, Tacrolimus (Prograf), Cyclosporine (Neoral), and Imuran (Azathioprine), fall within this category. Tacrolimus (Prograf) and Cyclosporine (Neoral) act by inhibiting IL-2 expression and lymphocyte activation, while Imuran (Azathioprine) inhibits purine nucleic acid metabolism (Naik & Shawar, 2020). The latter cause GI disturbances and myelosuppression, while Tacrolimus (Prograf) and Cyclosporine (Neoral) are linked to nephrotoxicity, hypertension, and hyperglycemia.

References

• Cashion, A. K., Hathaway, D. K., Stanfill, A., Thomas, F., Ziebarth, J. D., Cui, Y., Cowan, P. A., & Eason, J. (2014). Pre-transplant predictors of one yr weight gain after kidney transplantation. Clinical transplantation, 28(11), 1271–1278. https://doi.org/10.1111/ctr.12456
• Justiz. V., Waheed, A., Fan, J., Misra, S., & Fitzgerald, B. M. (2018). Acute Transplantation Rejection. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535410/
• Naik RH, Shawar SH. Renal (2020). Transplantation Rejection. [Updated 2020 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553074/
• Starzl, T. E., Rosenthal, J. T., Hakala, T. R., Iwatsuki, S., Shaw, B. W., Jr, & Klintmalm, G. B. (2011). Steps in immunosuppression for renal transplantation. Kidney international. Supplement, (14), S–65.