SOAP note genitourinary case by 04/22/2022,please add references and citations

turn off anonymous marking

Please state reason for turning off Anonymous Marking for: Warning: Administrator has access to this information. This setting is permanent.

This is a preview of the print version of your report. Please click "print" to continue or "done" to close this window.

done color-code matches: yes no default mode: show highest matches together show matches one at a time quickview (classic) report auto-navigation: jump to next match scroll to next match Save Cancel

• Word Count: words
• Percentage: %

or Cancel

• preferences

Turnitin Originality Report

• Processed on: 20-Apr-2022 4:48 PM EDT
• ID: 1815747047
• Word Count: 1161
• Submitted: 1

SOAP NOTE EDITED.docx By Ivis PEREZ DELGADO

  Similarity Index 33% Similarity by Source

Internet Sources:

12%

Publications:

4%

Student Papers:

28%

3% match (student papers from 15-Mar-2021)

Submitted to South University on 2021-03-15

2% match (student papers from 18-Apr-2019)

Submitted to South University on 2019-04-18

2% match (student papers from 05-Feb-2021)

Submitted to South University on 2021-02-05

2% match (student papers from 04-Dec-2017)

Submitted to South University on 2017-12-04

2% match (student papers from 25-Nov-2018)

Submitted to South University on 2018-11-25

2% match (student papers from 09-Sep-2021)

Submitted to South University on 2021-09-09

2% match (student papers from 14-Oct-2019)

Submitted to South University on 2019-10-14

2% match (student papers from 24-Jan-2017)

Submitted to EDMC on 2017-01-24

2% match (student papers from 24-Jan-2017)

Submitted to EDMC on 2017-01-24

2% match (Internet from 31-Jul-2020)

https://www.coursehero.com/file/27570048/Adult-WK-6-DB-GI-probsdocx/

2% match (Internet from 22-Dec-2017)

http://docplayer.net/10824766-Alberta-treatment-guidelines-for-sexually-transmitted-infections-sti-in-adolescents-and-adults-2012.html

1% match (student papers from 23-May-2020)

Submitted to South University on 2020-05-23

1% match (student papers from 11-Feb-2019)

Submitted to South University on 2019-02-11

1% match (student papers from 04-Aug-2019)

Submitted to South University on 2019-08-04

1% match (student papers from 03-Jan-2019)

Submitted to South University on 2019-01-03

1% match (student papers from 28-Jun-2021)

Submitted to South University on 2021-06-28

1% match (student papers from 21-Oct-2018)

Submitted to South University on 2018-10-21

1% match (student papers from 13-Apr-2022)

Submitted to South University on 2022-04-13

1% match (Internet from 18-Feb-2022)

https://ebin.pub/ferris-clinical-advisor-2021-5-books-in-1-0323713335-9780323713337.html

1% match (Internet from 10-Sep-2019)

http://www.recruitingunblog.com/the-talent-tipping-point/

1% match (Internet from 06-Dec-2021)

http://repository.poltekkes-kaltim.ac.id/679/1/Adult-Gerontology%20Nurse%20Practitioner%20Certification%20Intensive%20Review%2C%20Third%20Edition_%20Fast%20Facts%20and%20Practice%20Questions%20%28%20PDFDrive.com%20%29.pdf

1% match (Internet from 07-Apr-2022)

https://studyres.com/doc/8714114/pid?page=1

1 SOAP NOTE GENITOURINARY CLINICAL CASE IVIS PEREZ South University Online NSG 6001 Patient Initials : MS Subjective Data : The patient who is a 28-year-old female reports a history of frequency of pain and burning sensations during urination . The patient has experienced vaginal discharge and abdominal pain over the past week . The patient further states that approximately 2 days ago she started suffering from symptoms akin to urinary tract infection (UTI). She further reports of a brown foul-smelling discharge, which occurs each time after having unprotected sex with her ex- boyfriend and, she reports severe low abdominal pain. Chief Compliant:” I have frequency of pain and burning sensation upon urination, vaginal discharge, and abdominal pain.” History of Present Illness: A 28-year-old female who reports severe abdominal pain, presents with recurring UT symptoms of frequency of pain and burning sensation, which started two days ago. Patient further reports brown foul smelling discharge after having unprotected sex. PMH/Medical/Surgical History: Gonorrhea X2, Gravida IV Para III , Chlamydia X, Recurrent UTIs (3 this year). Significant Family History: Patient currently resides with her new boyfriend and her three children ; she has a history of several or multiple male sexual partners. Social History : Patient denies drug use either smoking, alcohol or any other form of drugs. Review of Symptoms : Patient denies breast discharge, had a pap smear six months ago, positive for urine having a dark color, frequency in pain and burning during urination, vaginal discharge and abdominal pain. Objective Data: Vital Signs: BMI 23.4 , RR 16, BP 100/80 , T 99.7 F , HR 80, Wt. 120, Ht. 5’ 0” Physical Assessment Findings: (Includes full head to toe review) HEENT : oral cavity without lesions; PERRLA Neck: no lymphadenopathy Carotids: No masses noted and strong pulses Lungs: Sounds clear to auscultation Heart: rhythm normal S1 and S2 , and regular rate Abdomen: increased suprapubic tenderness , tender and soft, non-distended no masses Genital/Pelvic: cervical motion sensitivity, foul odor in her vaginal discharge, Adnexal tenderness, Rectum: WNL Extremities/Pulses: pulses are normal, no evidence of bruising, WNL. Neurologic: intactness of cranial nerves, A&O X3 Laboratory and Diagnostic Test Results : Actual Value Normal Reference Value (Fischbach , 2014) Differential Bands 7% Monocytes 8% Neutrophils 68% Lymphocytes 13 % Eosinophils 2% Urinalysis Urine Ph 8.0 4.5–8.0 Specific Gravity 1.015 1.005–1.025 Color Straw colored Pale yellow to amber Protein Negative negative Ketones Negative negative Glucose Negative negative Bacteria * Many negative RBCs * 0-1 negative Urine Gram Stain *Gram negative rods Leukocytes *10-15 negative Cultures Wet prep negative VDRL negative Vaginal Culture * Monoclonal AB, sensitivities pending. Gram negative diplococci, *Positive-Chlamydia KOH prep negative Plan of Care: Gonorrhea unspecified ICD10 A54.9: Gonococcal infection is a diagnosis that can be made based on XX history of recurrent STIs and urinary tract infections and XX promiscuous behavior. Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative diplococcus N gonorrhoeae. Symptoms in men can include a purulent urethral discharge, whereas in women, it can be asymptomatic in up to 80 percent of cases. It is possible to develop gonorrhea on the mucocutaneous surfaces of the conjunctiva, pharynx, genitourinary tract, and anus (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017 ). As contagious as it can be the disease is transmitted through sexual intercourse and during childbirth, and it can have fatal effects. To confirm the diagnosis of gonorrhea, an NAAT (nucleic acid amplification test) is performed in conjunction with vaginal swabs and cultures ( Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). The most suitable treatment for gonorrhea, based on the CDC, is a single dose of 500 mg of intramuscular Ceftriaxone. CDC permits alternative regimens of treatment for rectal or urogenital gonorrhea. Permanent damage done by the disease will not be repaired by medication, although the prescription will help hat the disease. Notifying your intimate partner(s) of the infection and advising them to get medical attention. Taking medication as directed by a physician. Practicing safe sex acts, such as limiting the number of intimate partners , abstaining from sexual behaviors, and /or using condoms regularly and appropriately, to achieve efficient prevention of STDs and HIV transmission (CDC, 2015). Chlamydial infection, unspecified ICD 10 A74.9. Since XX is a high-risk sexual partner with a history of STIs and urinary tract infections (UTIs), the inclusion of chlamydia in the diagnosis is considered suitable. The bacteria Chlamydia attacks the columnar epithelial cells at the transition zone of the endocervix in women , resulting in an inflammatory response similar to that of Gonorrhea. NAATs are the recommended diagnostic method, and the general incubation period is between 1 and 2 weeks, depending on the strain ( Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017 ). Due to the presence of chlamydia, Gonorrhea, and a UTI in the same patient, XX must receive antibiotic therapy. Ceftriaxone 250 mg IM one dose plus Doxycycline 100 mg PO BID for 14 days , and Flagyl 500 mg PO BID for 14 days . Patient education is essential to assist the patient in avoiding risky habits such as unprotected sex. Taking the prescribed prescription as directed by medical practitioner, notifying one’s sexual companion(s) of infection; Instructing one’s companion to seek medical treatment. Using safe sex practices such as which consist of reducing the number of sexual or intimate partners, abstinence from harmful sexual acts, consistent and correct use of condoms in preventing HIV infection and STDs (CDC, 2 0 1 5 ). Treating patient for UTI. UTI ICD 10 N39.0 In the case of XX, recurrent urinary tract infections (UTIs ) or urinary tract infection (UTI) is a permissible diagnosis because her history of reoccurring UTIs. Most recurrent urinary tract infections (UTIs) are caused by the same pathogens being infected repeatedly, which is related to having regular sexual contact. Urinary tract infections (UTIs) are higher in some patient populations, such as younger, sexually active women and the elderly. By 32, over half of all women have reported having at least one urinary tract infection ( UTI ). Pathophysiology of UTIs in women is thought to be caused by the ascension of bacteria from the perianal area or peri-urethral ( Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017 ). Antibiotics are the most suitable therapeutic treatment for UTI related infections. Treatment recommended for CDC include Bactrim DS 1 tab every 12 hrs for 10 -14 days. (CDC.gov). Instructions: Taking medicine as recommended. Practicing safe sex practices. Drinking adequate amounts of fluids approximately, sixty-four to approximately eighty ounces of cranberry juice, frequent urination, wiping from front to back, and shunning female hygiene products that have creams especially in the genital regions (Bailey, 2013). Seeking medical treatment immediately after detection of frequent signs and symptoms of UTI . In case the current symptoms deteriorate during or after treatment -none should seek medical intervention. References Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary Care: A Collaborative Practice (5th ed.). St. Louis, MO: Elsevier. ISBN: 978-0-323-35501. www.CDC.gov Bailey, P. P. (2013). Infectious processes: Urinary tract infections and sexually transmitted infections. Primary care, (4th Ed, pp. 732-750). [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/ Center for Disease Control and Prevention. (2015). Clinical prevention guidelines. 2015 Sexually transmitted diseases treatment guidelines. Retrieved from https://www.cdc.gov/std/tg2015/clinical.htm SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case SOAP note Genitourinary clinical case