SOAP note week 3jorged021491
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.
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©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
- Patient Setting:
- Past Surgical History
- Family/Social History
- Medication History
- Physical exam
- Laboratory and Diagnostic Testing