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 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. Page 2 of 3 Advanced Nursing Practice I ©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 Page 3 of 3 Advanced Nursing Practice I ©2016 South University Running head: NAME OF CARE PLAN 1 Title of Plan of Care Name South University Online Faculty Name NSG 6001 Date 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, psychi.

1. 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

2. 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.
Page 2 of 3
Advanced Nursing Practice I

3. ©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
Page 3 of 3
Advanced Nursing Practice I
©2016 South University
Running head: NAME OF CARE PLAN 1

4. Title of Plan of Care
Name
South University Online
Faculty Name
NSG 6001
Date

5. 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,

6. 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:

7. 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 3
References