week 4 mid wk assignment advance nursing

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

Week 4: Genitourinary Clinical Case

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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

Template

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

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References

This is the link to the access code: https://www.cms.gov/medicare-coverage-database/search.aspx?error=Please%20use%20the%20new%20MCD%20Search%20to%20find%20documents%20with%20ICD-10%20codes.