SOAP Note Assignment Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan
Week 4: Genitourinary Clinical Case
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.
HPIComplains 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.
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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.
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Advanced Nursing Practice I
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
