NSG 6001 Week 4 SOAP Note Assignment
NSG 6001 Week 4 SOAP Note Assignment
Patient Initials P.B
Subjective Data:
Chief Compliant: “Increased urinary frequency, burning sensation, and pain when voiding.”
History of Present Illness:
P.B. is a 28-year-old White with a chief complaint of increased urinary frequency, burning sensation, and pain when voiding. She noticed the symptoms two days ago. She reports that she had similar urinary symptoms in her previous UTIs. The urinary symptoms are associated with increased lower abdominal pain and vaginal discharge, which have been present in the past week. She states that the lower abdominal pain is severe. She describes the vaginal discharge as brown and foul-smelling and started after having unprotected intercourse with her ex-boyfriend.
PMH/Medical/Surgical History:
No current medications.
Allergies- Trimethoprim /Sulfamethoxazole causes a rash.
No history of chronic illnesses.
History of Recurrent UTIs, three times this year; History of gonorrhea 2 episodes and Chlamydia infection 1 episode.
Para 3 Gravida 4.
Tubal ligation 2 years ago.
Significant Family History: No chronic illnesses in the family.
Social History: P.B. is single and lives with her new boyfriend and three children. She has a history of multiple male sexual partners. She denies tobacco smoking or alcohol and drug use.
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Review of Symptoms:
General: Denies weight changes, fever, or fatigue.
Integumentary: Negative for rashes, lesions, or itching.
Head: Denies trauma or headaches. Eyes: Denies blurred/double vision or eye pain. ENT: Denies ear pin, tinnitus, hearing loss, sneezing, nasal discharge, or sore throat.
Cardiovascular: Denies palpitations, chest pain, or exertional dyspnea.
Respiratory: Denies chest pain, breathing difficulties, wheezing, or cough.
Breasts: Denies breast discharge.
Gastrointestinal: Reports lower abdominal pain. Negative for nausea, vomiting, or bowel changes.
Genitourinary: Last pap- 6 months ago. Increased brown, foul-smelling vaginal discharge; Dark urine; increased urinary frequency; burning sensation; pain on urination. Musculoskeletal: Denies muscle, joint, or back pain or joint stiffness.
Neurological: Denies loss of consciousness, paralysis, or tingling sensations.
Endocrine: Denies cold/ heat intolerance, excessive sweating, or increased thirst/hunger. Hematologic: Negative for bruising or bleeding.
Psychological: Denies anxiety or depression symptoms.
Objective Data:
Vital Signs: Vital Signs: BP -100/80, P- 80; R: 16; T: 99.7 F; Wt. 120 lbs.; Ht.5’0; BMI 23.4.
Physical Assessment Findings:
General: Female patient in moderate distress.
HEENT: WNL.
Lymph Nodes: No lymphadenopathy.
Carotids: Negative for bruits
Lungs: WNL.
Heart: RRR. Normal S1 and S2.
Abdomen: Soft and tender on palpation with suprapubic tenderness.
Genital/Pelvic: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage.
Rectum: WNL.
Extremities/Pulses: WNL.
Neurologic: WNL.
Laboratory and Diagnostic Test Results: (Include result and interpretation.)
Leukocyte differential: Neutrophils 68%, Lymphs 13%, Bands 7%, Monos 8%, EOS 2%.
Urinalysis: Straw-colored. Specific gravity- 1.015; pH- 8.0; Protein-negative; Glucose- negative; Ketones- negative; Bacteria – numerous, Leukocytes: 10-15; RBCs 0-1.
Urine gram stain – Gram-negative rods.
PV discharge culture: Gram-negative diplococci, Neisseria gonorrhoeae, sensitivities pending.
Positive monoclonal A.B. for Chlamydia, KOH preparation, Wet preparation, and VDRL negative.
Assessment:
Pelvic Inflammatory Disease (PID) ICD10- N73.9): The patient presents with symptoms consistent with PID, like burning and pain sensation when voiding, foul-smelling brown vaginal discharge, and lower abdominal pain. She has a history of Gonorrhea and Chlamydia infections, which probably ascended to the upper genital tract causing inflammation and PID. Her sexual history of multiple sexual partners puts her at risk of PID (Brun et al., 2019). In addition, physical exam findings consistent with PID in the patient include mild fever at 99.7F, abdominal tenderness, suprapubic tenderness, adnexal and cervical motion tenderness, and foul-smelling vaginal discharge. Furthermore, Positive monoclonal A.B. for Chlamydia suggests PID secondary to infection by Chlamydia trachomatis (Brun et al., 2019).
Cervicitis (ICD10- O86.11): The patient’s history of gonorrhea and chlamydia and multiple sexual partners increases her risk of cervicitis. The infection ascends the genital tract, causing cervix inflammation and resultant cervicitis (Bansal et al., 2022). The positive monoclonal A.B. for Chlamydia suggests cervicitis caused by Chlamydia infection. The patient presents with clinical features of cervicitis like pain when urinating, urinary frequency, foul-smelling increased vaginal discharge, lower abdominal pain, suprapubic tenderness, cervical motion tenderness, and adnexal tenderness (Bansal et al., 2022).
Cystitis (IKCD 10- N30. 90): The clinical manifestations of cystitis include dysuria, urinary frequency, urgency, small volumes of urine, low back pain, suprapubic pain, and nocturia. The patient presents with positive findings of cystitis, like burning sensation and pain during urination, increased urinary frequency, and suprapubic tenderness (Frazier & Huppmann, 2020). B Besides, lab results support cystitis like straw-colored urine, high leukocytes on UA, numerous Bacteria, and the presence of Gram-negative rods.
Plan of Care:
PID
Pharmacologic treatment: The indicated first-line treatment for uncomplicated PID includes a combination of:
Ceftriaxone 1g STAT dose IM or IV route
Doxycycline 100mg BID orally for 14 days
Metronidazole 500mg BID oral for 14 days (Yusuf & Trent, 2023).
Health education & counseling: Health education on medication adherence to prevent re-infection. Counseling on safe sexual practices like using condoms and limiting the number of sexual partners. The patient will be advised to abstain from sexual practices until after the completion of the dose and the infection has abated (Yusuf & Trent, 2023).
Cervicitis
Pharmacologic treatment: The recommended treatment for cervicitis secondary to Chlamydia infection is:
Azithromycin 1 g orally OD or Doxycycline 100 mg orally BD for 7 days (Bansal et al., 2022).
Health education & counseling: The patient will be advised to have her sex partners tested and treated simultaneously since the cause of the cervicitis is a bacterial STI. She will be advised to abstain from sexual intercourse until the infection is eliminated from her and all her sex partners (Bansal et al., 2022). Health education on safe sexual practices, including using barrier protective methods to protect herself from STIs.
Cystitis
Pharmacologic treatment: The first-line treatment of uncomplicated cystitis is:
Nitrofurantoin 100 mg orally BD for 5 days (Frazier & Huppmann, 2020).
Health education & counseling: The patient has had three UTIs this year.
She will be educated on preventive measures for UTI, including: Increasing fluid intake, avoiding the use of spermicides and diaphragm, avoiding delaying urination, wiping front to back after defecation, urinating immediately after sexual intercourse, and avoiding douching (Jelly et al., 2022).
NSG 6001 Week 4 SOAP Note Assignment References
Bansal, S., Bhargava, A., Verma, P., Khunger, N., Panchal, P., & Joshi, N. (2022). Etiology of cervicitis: Are there new agents in play? Indian Journal of sexually transmitted diseases and AIDS, 43(2), 174–178. https://doi.org/10.4103/ijstd.ijstd_75_21
Brun, J. L., Castan, B., de Barbeyrac, B., Cazanave, C., Charvériat, A., Faure, K., Mignot, S., Verdon, R., Fritel, X., & Graesslin, O. (2019). Les infections génitales hautes. Mise à jour des recommandations pour la pratique clinique – texte court [Pelvic Inflammatory Diseases: Updated Guidelines for Clinical Practice – Short version]. Gynecologie, obstetrique, fertilite & senologie, 47(5), 398–403. https://doi.org/10.1016/j.gofs.2019.03.012
Frazier, R. L., & Huppmann, A. R. (2020). Educational Case: Acute Cystitis. Academic pathology, 7, 2374289520951923. https://doi.org/10.1177/2374289520951923
Jelly, P., Verma, R., Kumawat, R., Choudhary, S., Chadha, L., & Sharma, R. (2022). Occurrence of urinary tract infection and preventive strategies practiced by female students at a tertiary care teaching institution. Journal of Education and health promotion, pp. 11, 122. https://doi.org/10.4103/jehp.jehp_750_21
Yusuf, H., & Trent, M. (2023). Management of Pelvic Inflammatory Disease in Clinical Practice. Therapeutics and clinical risk management, 19, 183–192. https://doi.org/10.2147/TCRM.S350750
Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.
Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
Download the access codes.
Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note.
