Analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.
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- SOAP note
- Evaluation of priority diagnosis
- Facilitators and barriers to disorder management
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
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) rash
NKDA
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.
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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