Genitourinary Clinical Case Assignment

Genitourinary Clinical Case Assignment Genitourinary Clinical Case Assignment Title: Genitourinary Clinical Case Patient Setting: 28 year old female presents to the clinic with a 2 days history of frequency, burning and pain upon urination; increase lower abdominal pain and vaginal discharge over the past week. Genitourinary Clinical Case Assignment 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. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS PMH Recurrent UTIs (3 year); gonorheax2; chlamydia X1; Gravida IV Para III. Past Surgical History Tubal Ligation 2 years ago. Family/ Social History Family: Single; history of multiple sexual partners; currently leaves with new boyfriend and two children. Social: Denies smoking, alcohol and drug abuse. Medication History None Trimethoprim (TOM) Sulfamethoxazole (SMX) rash. NKAD ROS Last pap 6 months ago, Denies breast discharge. Positive for urine to look 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, increase suprapubic tenderness. GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage. Rectal: WNL. EXT: WNL. NEURO: WNL. Laboratory and Diagnostic Testing – Genitourinary Clinical Case Assignment Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 7%, Monos 8%, EOS 2 % UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketone neg, Bacteria- many Lcks 10-15, RBC 0-1 Urine gram stain- Gram negatives rods Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative Pleased fallow this instructions. This is the criteria my instructor will use to grade me. With this case study analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for this patient and disorder for the patient in the clinical case. The 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. Provide at least 3 differentials medical diagnosis and a plan of car for each. Provide Journals and research articles 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, and 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. SOAP note Evaluation of priority diagnosis Facilitators and barriers to disorder management Assignment Grading Criteria Introduction 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. Assessment 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. Genitourinary Clinical Case Assignment Facilitators and Barriers The submission interpreted facilitators and barriers to optimal disorder management and outcomes and strategies to overcome the identified barriers. Conclusion The submission included what should be taken away from this assignment. APA/Style/Format 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. This is the care plan template you need to fill it out base on the patient information on the case study. Provided below. Please try to reword the information, do not use the exact words to fill out the **Please delete this statement and anything in italics prior to submission to shorten the length of your paper. Care Plan Template Patient Initials : J.J 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). References pleased_fallow_this_instructions.docx care_plan_case_study__analisys.docx care_plan_sample.docx Sample Care Plan This a sample of a case stydy and a care plan that I did for the same professor, but this is a different case. Please fallow the same format. Included an attachment copy also. Please let me know if you need more information. Cardiovascular Clinical Case Patient Setting: 52 year old Irish American Male that was hospitalized 2 weeks ago for a stent placement. Presenting to your clinic today for follow up as he has not felt well. He sates he has been lightheaded and felt palpitations of his heart. He has also had shortness of breath the last 2 days. HPI Walks 2 miles daily and rides an exercise bicycle 3 times a week; has previously felt the palpitations associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away but they have continued and that is why he is here today. PMH History of hypertension for 10 years, hyperlipidemia for 5 year, status post stent placement 2 weeks ago, and rheumatic heart disease (mitral valve) as a child. He reports adhering to a low cholesterol low fat diet for the last 2 years. Past Surgical History Stent placement 2 weeks ago. Family/Social History Family: Noncontributary Social: Smoked 15 pack/year X 20 years. Quit 5 years ago. Medication History Lisinopril 20 mg PO QD Furosemide 20 mg PO QD Gemfibrozil 600 mg PO BID Allergies NKDA ROS Otherwise negative. Physical exam BP 160/90 (clinic visit 2 months ago 155/85) HR 146, RR 22, T 98.6 F, Wt 254, Ht 5’ 7” Gen: Well developed male in moderate distress. HEENT: PERRLA, (-) JVDm mild AV nicking. Cardio: Rate irregularly irregular, no murmurs or gallops. Chest: Clear to auscultation. Abd: soft, non-tender, active bowel sounds. GU: Deferred. Rectal: Normal. EXT: No edema, normal pulses throughout. NEURO: A&O X3. Genitourinary Clinical Case Assignment Laboratory and Diagnostic Testing Na – 136 K – 4.5 Cl – 97 BUN – 20 Cr – 1.2 Total Chol – 240 Trig – 180 INR – 1.1 Chest Xray – Clear ECG – Atrial Fibrillation, no P waves, variable R-R interval normal QRS Title: Running Head Cardio Vascular Clinical Case Care Plan Name Institution Instructor Class Date Patient Initials J.D Subjective Data: According to Mr. J.D, he is 52 years old. He is an older adult Irish American male, that been out of hospital for the past 2 weeks. He arrived to the health center for fallow up due to not feeling well with symptoms of lightheaded, palpitation of his heart and shortness of breath the last 2 days. No known allergies reported. Chief Compliant: Lightheaded, Palpitations of his heart and shortness of breath History of Present Illness: Mr. J.D reported to Walk 2 miles daily and cycles an exercise bicycle 3 times a week; he reported that previously felt the palpitations associated with exercise that usually went away with rest; 2 days ago while washing dishes he began to feel shortness of breath and felt that his heart was “racing”; He hoped the palpitations would go away but they have continued and that is why he is here today. PMH/Medical/Surgical History: Mr. J.D reported to been diagnose with the following disease of hypertension for 10 years, hyperlipidemia for 5 year, status post stent placement surgery 2 weeks ago, and rheumatic heart disease (mitral valve) as a child. Mr. J.D reports to stick to a low cholesterol and low fat diet for the last 2 years. Patient reported to have noncontributory when it comes to family history. Mr. J.D reported to have a history of smoking 15 pack a year for 20 years and stop smoking since 5 years ago. Patient is currently taking the following medications Lisinopril 20 mg by mouth every day for blood pressure, Furosemide 20 mg oral daily and Gemfibrozil 600 mg by mouth two times daily to reduce cholesterol and Triglycerides Significant Family History: Noncontributary Social History : Mr. J.D is an older adult Irish American male reported walking 2 miles daily and rides an exercise bicycle 3 times a week and to smoke 15 pack a year for 20 years. No home living situation, marital status, religious practice, educational background, occupational history, financial security nor family history of violence have been report it. Review of Symptoms: General : 52 year old Irish American male patient observed with normal appearance and look well developed for his age but remains in mild distress. Genitourinary Clinical Case Assignment Integumentary : Is warm and dry to touch, uniform in color, umblemished and no abnormal body smell noted. Head : Denies Eyes: Patient’s pupils of the eyes noted equally round respond to light accommodation. Arteriovenous nipping of the eyes noted, meaning small artery is seen crossing a small vein, which results in the compression of the vein with bulging on either side of crossing. Cardiovascular: Patient’s heart rate note irregularly irregular, no murmurs or gallops. Respiratory : Mr. J.D lung sound is clear to auscultation. Gastrointestinal : Patient abdomen area observed with no distention, soft and bowel sound are present on all four quadrants. Genitourinary : Did not assess. Musculoskeletal : Bilateral upper and lower extremities pulses are present and normal and sign of edema noted. Neurological : Patient observed awake, alert and oriented x3 Endocrine: Did not assess. Hematologic : Sodium level 136, potassium 4.5, CL 97, BUN 20, Cr 1.2, Total Cholesterol 240, Triglyceride 180 and INR 1.1 Psychologic : Deferred Objective Data: Vital Signs: BP 160/90, P 146 R22, T 98.6, Wt. 254, Ht. 5’7” BMI 34 Physical Assessment Findings: HEENT : Patient head observed rounded, normocephalic and symmetrical. No nodules, masses nor depression noted upon palpation of the patient skull. Mr. J.D face noted very smooth, equal without any lumps noted. Patient’s pupils of the eyes noted to be black and equal in size. The iris observed flat and round. Pupils equally round respond to light accommodation. Arteriovenous nipping of the eyes noted, meaning small artery is seen crossing a small vein, which results in the compression of the vein with bulging on either side of crossing. ENT: Ears Auricles are symmetrical and has the color with patient’s face; it is appeared to be mobile, firm and not tender. The pinna recoils when fold. Mr. J.D able to hear well when whispered on bilateral ears Nose : Patient’s nose noted symmetric with the same color and smooth texture, no lesion, mass nor fluid noted. Hair is evenly distributed. Throat: mouth is pink and moist, symmetric and able to purse his lips. Lymph Nodes: No sign of enlarge nor painful lymph nodes noted Carotids: observed equal bilaterally, 2+ Lungs: Patient’s chest wall noted intact, no tenderness and masses noted when palpate. It is symmetrical and lung sound is clear when auscultated. Heart: Patient’s heart rate note irregularly irregular, no murmurs or gallops. Abdomen: Patient abdomen area observed with no distention, soft and bowel sound are present on all four quadrants. Genital/Pelvic: Deferred Rectum: Patient rectal area noted normal, no sign of lesion noted. Extremities/Pulses Resident Bilateral upper and lower extremities skin noted warm and dry to touch, all pulses are present and normal and no sign of edema noted. Neurologic: Patient observed awake, alert and oriented x3 and verbally responsive remains in stable condition. Laboratory and Diagnostic Test Results: Sodium level 136 Normal, Potassium 4.5 Normal, CL 97 Normal, BUN 20 Normal, Cr 1.2 Normal, Total Cholesterol 240 Abnormal, Triglyceride 180 Abnormal and INR 1.1 Normal. Assessment: Pulmonary Insufficiency ICD-10 codes J95.3, Obesity ICD-10 codes E66.01, Activity Intolerance ICD-10 Codes Z73.89 Plan of Care: ( Addressing each dx with diagnostic and therapeutic management as well as education and counseling provided ). Diagnosis: Pulmonary Insufficient and Activity intolerance related imbalance between oxygen supply and demand as evidence by shortness of breath and palpitation, increase blood pressure and increase heart rate Goals and outcomes: Mr. J.B will maintain blood pressure and heart rate level within normal limits 5 minutes after exercise and dialing activity. Patient will report no sign of shortness of breath, lightheaded during exercise and daily activity. Mr. J.D will identify methods to reduced activity daily intolerance and the ability to perform daily exercise. Intervention: As a nurse practitioner I will establish guidelines and goals of activity with Mr. J.D. I will administer the following 2 liters of oxygen will be administered via nasal cannula to help with the symptoms of shortness of breath and to promote tissue perfusion. I will administer one dose of clonidine tablet 01. Mg by mouth to help decrease the blood pressure and bisoprolol fumarate 5 mg tablet by mouth stat to decrease the heart rate. Patient will remains in the clinic until all symptoms clear. Patient will be prescribed routine 5 mg bisoprolol fumarate by mouth daily for diagnosis of Atrial Fibrillation and 3 mg warfarin daily by mouth to prevent blot clot. 1 tablet of Metoprolol 25 mg oral by mouth for blood pressure and pulse and 1 tablet of Nefedipine 20 mg oral daily for blood pressure and pulse. Patient will advise to continued taking the following medications Lisinopril 20 mg by mouth every day for blood pressure, Furosemide 20 mg oral daily and Gemfibrozil 600 mg by mouth two times daily to reduce cholesterol and Triglycerides I will teach patient how to perform frequent daily deep-breathing exercise. Mr. J.D will receive emotional support and positive attitude in regards to perform daily exercise and activity. Primary care provider will teach patient how to perform pursed-lip, diaphragmatic and abdominal breathing to improve shortness of breath during physical and daily activity. Nursing diagnosis: Obesity related to weight as evidence by body mass index result. As the patient’s primary care provider, I will educate to him to follow a good heart healthy diet to help reduced the excessive body weight, blood pressure and cholesterol level by consumed lot of fruits, vegetables, whole grain, nuts, legumes, fish, olive oil, low salt diet. Patient is encouraged to perform at least 40 minutes of exercise per day. For instance walking, jogging, swimming, biking walking and dancing and to stop when feeling shortness of breath, lightheaded and palpitation., as a result, his cholesterol, blood pressure level will be under, no more plaques will be buildup to the arteries. The following laboratory and medical tests will be perform periodically to monitor drug side effect and patient’s system: Cholesterol and triglycerides levels, Kidney, liver function tests, complete blood count As the patient primary care provider, I will teach him to call 911 if notice any sign of heart attack( Shortness of breath, indigestion, chest pain radiate to neck, arm, lower back and jaw). Patient will be educating regarding all medications sign and symptoms. To take daily cholesterol, blood pressure, heart medication and anticoagulants medications as fallow by the primary care provider to prevent any further complication. Genitourinary Clinical Case Assignment Patient will be educate to come to the clinic every Monday for PT/INR level monitoring Thyroid function test will be assess Hemoglobin A1C tests to rule out diabetes do to Obesity. Education will be provided to patient to avoid green leafing vegetable to prevent the positive effect of the Coumadin To drink plenty of fluid and to perform moderate exercise and to take break between activities. Patient will provide a referral to fallow up with a cardiologist. Patient will be referred to Cardia rehabilitation program in other to obtain supervision with daily exercise, medication therapy, and daily diet. Patient will be encourage minimizing the level of anxiety and stress by doing Meditation, listen to music, Use guide imaginary, let the negative feeling out, to something he is enjoy, practice writing and practice favorite hobbies Education will be provided to patient to avoid green leafing vegetable to prevent any negative effect. Avoid vitamin K injection and food that contain vitamin K on them. Patient will teach to avoid coffee, cola, soda any tea that have caffeine and alcohol. Patient will encourage to shave with electrical razor only and to avoid been cut or injured to prevent bleeding. Patient will be educating to return to follow up appointment in two weeks. Patient will be educating to get plenty of rest and to get sleep at least 8 hours of sleep daily. References Angioplasty and vascular stenting. (2014, August 22). Retrieved from http://www.radiologyinfo.org/en/info.cfm?pg=angioplasty Venuta, F., Rendina, E.,&De Giacomo,T.(2015,octorber 21). Airway senting.Retrieved from http://.ctsnet.org/sections/clinicalresources/thoracic/ecpert_tech-1 American heart association recommendations for physical activity in adults.(2016, July 27).Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-Heart-Association-Recommendations-for -Physical-Activity-in Adults_UCM_307976_Article.jsp#.V5P9XyMrjhB. McCance, K. L., & Huether, S. E. (2014). Pathophysiology: the biologic basis for disease in adults and children. Seventh edition. St. Louis, Missouri: Elsevier. External resources American Heart Association (AHA).Retrieved from http://www.americanheart.org. 4Belza B, Walwick J, Shiu-Thornton S, et al. Older adult perspectives on physical activity and exercise: Voices from multiple cultures. Prev Chronic Dis. 2004 Oct;1(4):A09 [cited 2014 Mar 22].Retrieved from: http://www.cdc.gov.ezproxyhhs.nihlibrary.nih.gov/pcd/issues/2004/oct/04_0028.htm Genitourinary Clinical Case Assignment Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10