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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

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

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.:
Genitourinary Clinical Case 3 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: Gramnegative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative

SOAP FORMAT
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, 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: 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).

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