Genitourinary case study

Genitourinary case study

Patient Setting:
A 28 year old female presents to the clinic with 2 days history of frequency, burning and pain upon urination, increased lower abdominal pain and vaginal discharge over the past week.

complains of urinary symptoms similar to those of previous urinary tract infection(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 formal boyfriend.

Reccurent 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
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) rash

Last pap 6 months ago. Denies breast discharge. Positive for urine lookin dark.

Physical Exam
BP 100/80, HR 80, RR 16, T 99.7, wt 120lb, Ht 5’0″

Gen: female in moderate distress.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL
Abd: Soft, tender, increase suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
Neuro: WNL

Laboratory and diagnostic testing
Lkc differential: Neutrophils 68%, Bands 7%, lymphs 13%, monos 8%, EOS 2%.,
UA: Starw colored. sp gr , ph 8.0, protein neg, ketones neg, bacteria-many, Lkcs 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.

Assignment 2 Grading Criteria

The submission included a general introduction to the priority diagnosis.

Subjective Data

The submission included the patient’s interpretation of current medical problem. It included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.

Objective Data

The submission included the measurements and observations obtained by the nurse practitioner. It included head to toe physical examination as well as laboratory and diagnostic testing results.


The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.

Plan of Care

Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.

Evaluation of Priority Diagnosis

The plan chose the priority diagnosis for the patient and differentiated the disorder from normal development. Discussed the physical and psychological demands the disorder places on the patient and family and key concepts to discuss with them. Identified key interdisciplinary team personnel needed and how this team will provide care to achieve optimal disorder management and outcomes.

Facilitators and Barriers

The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers.


The submission included what should be taken away from this assignment.

The submission was free of grammatical, spelling, or punctuation errors. Citations and references were written in correct APA Style.
Utilized proper format with coversheet, header.