Download and analyze the case study?for this week (see files). Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case.

Week 4: Genitourinary Clinical Case © 2016 South University

2 Week 4: Genitourinary Clinical Case

Patient Setting: 28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week.

HPI Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls smelling discharge after having unprotected intercourse with her former boyfriend.

PMH Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III

Past Surgical History Tubal ligation 2 years ago.

Family/Social History Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3 children. Social: Denies smoking, alcohol and drug use.

Medication History None Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash ROS Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.

Physical exam BP 100/80, HR 80, RR 16, T 99.7 F, Wt 120, Ht 5’ 0”

Gen: Female in moderate distress. HEENT: WNL. Cardio: Regular rate and rhythm normal S1 and S2. Chest: WNL. Abd: soft, tender, increased suprapubic tenderness. GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage. Rectal: WNL.

Page 2 of 3 Advanced Nursing Practice I

©2016 South University

3 Week 4: Genitourinary Clinical Case

EXT: WNL. NEURO: WNL.

Laboratory and Diagnostic Testing Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2% UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10- 15, RBC 0-1 Urine gram stain – Gram negative rods Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative

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Advanced Nursing Practice I ©2016 South University

Running head: NAME OF CARE PLAN 1

Title of Plan of Care

Name

South University Online

Faculty Name

NSG 6001

Date

NAME PLAN OF CARE 2

**Please delete this statement and anything in italics prior to submission to shorten the length

of your paper.

Patient Initials ______

Subjective Data: (Information the patient tells you regarding themselves: Biased Information):

Chief Compliant: (In patient’s exact words)

History of Present Illness: (Analysis of current problems in chronologic order using symptom

analysis [onset, location, frequency, quality, quantity, aggravating/alleviating factors, associated

symptoms and treatments tried]).

PMH/Medical/Surgical History: (Includes medications and why taking, allergies, other major

medical problems, immunizations, injuries, hospitalizations, surgeries, psychiatric history,

obstetric and history sexual history).

Significant Family History: (Includes family members and specific inheritable diseases).

Social History: (Includes home living situation, marital history, cultural background, health

habits, lifestyle/recreation, religious practices, educational background, occupational history,

financial security and family history of violence).

Review of Symptoms: (Review each body system – This section you should place POSITIVE for…

information in the beginning then state Denies…). – General:; Integumentary:; Head:; Eyes: ;

ENT:; Cardiovascular:; Respiratory: ; Gastrointestinal:; Genitourinary:; Musculoskeletal:;

Neurological:; Endocrine:; Hematologic:; Psychologic: .

Objective Data:

Vital Signs: BP – ; P ; R ; T ; Wt. ; Ht. ; BMI .

Physical Assessment Findings: (Includes full head to toe review)

HEENT:

Lymph Nodes:

Carotids:

Lungs:

Heart:

Abdomen:

Genital/Pelvic:

Rectum:

Extremities/Pulses:

Neurologic:

Laboratory and Diagnostic Test Results: (Include result and interpretation.)

Assessment: (Include at least 3 priority diagnosis with ICD-10 codes. Please place in order of

priority.)

Plan of Care: (Addressing each dx with diagnostic and therapeutic management as well as

education and counseling provided).

NAME PLAN OF CARE 3

References