Genitourinary Clinical Case – SOAP Note

Patient Initials: J.S.

Subjective Data: A 28-year-old female patient complains about the frequency, dysuria and pain at urination. The patient has had worse lower abdominal pain and more vaginal discharge in the past week. She referred to it as smelling bad and being of a brown colour: Genitourinary Clinical Case – SOAP Note.

Chief Compliant: “Having recurrent UTIs, experiencing burning sensations while passing urine and having pain every time you pee, plus lower abdomen pain that becomes worse and constant massive discharge from the vagina.”

History of Present Illness: The exact onset of the patient’s urinary complaints started two days ago and include urgency, pain on urination and suprapubic pain, which is getting worse gradually. Such signs are the same as previous manifestations of UTI that have been experienced multiple times this year. She also mentions a dark brown thick amorphous vaginal discharge of foul smell lasting one week since unprotected intercourse with an ex-boyfriend.

Disputes the present-day relief or other self-chosen coping mechanisms. She denies fever, chills, or vomiting but does admit to discomfort and pain associated with her urinary symptoms.

PMH/Medical/Surgical History: The patient reports a past medical history of recurrent UTIs, having three episodes this year alone. Her history is also well-documented with sexually transmitted infections, including two episodes of gonorrhea and one episode of chlamydia. Obstetrically, she is Gravida IV, Para III, which denotes three live births. In the surgical history of the patient, there is a tubal ligation performed two years ago. Her denial is only for other important medical and psychiatric histories.

Significant Family History: The patient reports that none of her immediate family members have any known inheritable disorders that could immediately affect her current state of health.

Social History: The patient is single and says she has had several sexual encounters with males. She now resides in a new boyfriend’s house with her three children. She negates the use of cigarettes, liquor, marijuana, or other related products. This social history puts her at risk of getting recurrent STIs because of her sexual history. It would form part of her care plan to include counseling on safe sex practices and routine screenings to reduce the chance of future infections.

Review of Symptoms:

• General: Reports fatigue but fever, chills, or weight changes.
• Integumentary: The patient refutes any rashes or skin changes.
• HEENT: No complaints of headaches, vision changes, or sore throat.
• Respiratory: Wheezing, dyspnea, or coughing is absent.
• Cardiovascular: Chest pain, palpitations, or edema are not reported.
• Gastrointestinal: There is the presence of mild lower abdominal pain; denies nausea, vomiting, or bowel changes.
• Genitourinary: Denies hematuria or flank pain but reports dysuria, suprapubic pain, and foul-smelling vaginal discharge.
• Musculoskeletal: Indicates no stiffness, edema, or joint pain.
• Neurological: There are no reports of dizziness, weakness, or numbness.
• Endocrine: There is no mention of increased thirst or changes in appetite.
• Hematologic: No history of bruises or bleeding is present.
• Psychologic: Despite indicators of modest stress, the patient denies having anxiety or sadness.

Objective Data:

Vital Signs:

• BP: 100/80 mmHg
• HR: 80 bpm
• RR: 16 breaths/min
• T: 99.7°F
• Wt: 120 lbs
• Ht: 5’0”

Physical Assessment Findings:

• HEENT: The skin, head, and neck are intact, with no evidence of swellings, lumps, or masses. The HEENT is grossly normal and within the normal limit.
• Lymph Nodes: There is no cervical, axillary or inguinal enlargement of glands. Cervical, axillary, and inguinal nodes are non-tender and of normal size.
• Carotids: Feelings of the carotid pulses are bouncing on each side, and no bruits are audible. There was no distinguishable problem as far as auscultation around the carotid artery was concerned.
• Lungs: No rhonchi, wheezing, and rales are audible from both sides of the chest while auscultation. The patient reports no problem with breathing and does not present with cough and dyspnea; respiratory rate is intact.
• Heart: Normal S1 and S2 sounds at a regular pace and rhythm. Auscultation revealed no gallops, rubs, or murmurs. The patient’s cardiovascular examination is within normal limits.
• Abdomen: Soft but tender upon palpation in the suprapubic area, indicating lower abdominal discomfort. No rebound tenderness, guarding, or rigidity was observed, and bowel sounds exist and are normal in all quadrants.
• Genital/Pelvic: The pelvic exam shows cervical motion tenderness and adnexal tenderness consistent with pelvic inflammatory symptoms. A foul-smelling, brown vaginal discharge is noted, which seems copious in amount. These findings suggest a possible gonococcal or chlamydial infection.
• Rectum: Rectal examination is within normal limits (WNL), and no abnormalities or tenderness were noted.
• Extremities/Pulses: Extremities are without edema, cyanosis, or clubbing. Peripheral pulses are palpable and strong bilaterally.
• Neurologic: Neurological examination is unremarkable, with cranial nerves intact and no deficits noted. The patient’s reflexes are normal, and she has intact sensation and motor function.

Laboratory and Diagnostic Test Results:

• Leukocyte Differential: Neutrophils 68% | Bands 7% | Lymphocytes 13% | Monocytes 8% | Eosinophils 2%. These findings show an elevated neutrophil count, usually seen in bacterial infections, which supports the finding of active disease.
• Urinalysis (UA): The urine is straw-colored with a specific gravity of 1.015 and a pH of 8.0. Negative results for protein, glucose, and ketones. It shows several bacteria and leukocytes (10-15 per high-power field) with rare RBCs (0-1 per high-power field). The presence of bacteria and WBCs is compatible with a UTI.
• Urine Gram Stain: Gram staining confirms the diagnosis of a UTI by revealing Gram-negative rods, which suggest a bacterial urine infection.
• Vaginal Discharge Culture: Culture results reveal Gram-negative diplococci, which are consistent with Neisseria gonorrhoeae, indicating a gonococcal infection. Sensitivity results are still pending but will guide appropriate antibiotic therapy adjustments if needed.
• Monoclonal Antibody Test for Chlamydia: Positive for chlamydia, indicating a co-infection. This result supports a diagnosis of chlamydial infection, which is common in patients with gonorrhea.
• KOH Preparation: Negative for yeast, ruling out a fungal infection as a cause of the vaginal discharge.
• Wet Preparation and VDRL: Negative for trichomoniasis (wet prep) and syphilis (VDRL), ruling out these infections as contributors to the patient’s symptoms.

Assessment:

• Gonococcal Infection (ICD-10: A54.00): Confirmed by vaginal discharge culture showing Gram-negative diplococci, indicating a Neisseria gonorrhoeae infection (Cyr, 2020).
• Chlamydial Infection (ICD-10: A74.9): Positive chlamydia test, common as a co-infection with gonorrhea, explaining additional GU symptoms (Centers for Disease Control and Prevention, 2021).
• Recurrent Urinary Tract Infection (UTI)(ICD-10: N39.0): History of frequent UTIs with symptoms and findings consistent with another episode (Aggarwal & Lotfollahzadeh, 2022).

Plan of Care:

Diagnostics

Sensitivity testing is required for Neisseria gonorrhoeae to guide targeted antibiotic therapy. Additional STI testing is recommended, including HIV and syphilis, to ensure comprehensive management and identify any potential co-infections.

Therapeutic Management

• Antibiotic Therapy: Administer a 500 mg intramuscular dosage of Ceftriaxone to treat gonorrhea. To cure chlamydia, prescribe 100 mg of doxycycline twice a day for seven days (CDC, 2021).
• Symptomatic Relief: Advise increased fluid intake to help flush out the urinary tract and potentially relieve some discomfort associated with dysuria.

Patient Education and Counseling

Educate J.S. on completing the full course of prescribed antibiotics to avoid incomplete treatment and possible resistance. Counsel her to abstain from sexual activity until treatment is completed and confirm resolution with follow-up tests. Emphasize the use of condoms consistently and regular screening for STIs. Also, discuss potential long-term complications of untreated STIs, including PID, infertility, and possible systemic complications, as noted by Garcia and Wray (2024).

Follow-Up

Do a check-up after a week to check on the symptoms, the lab results, and the findings flagged by the sensitivity test. This also provides an avenue to repeat key messages concerning safe sex practices and STI prevention measures and further resources regarding sexual health education.

References

Aggarwal, N., & Lotfollahzadeh, S. (2022). Recurrent urinary tract infections. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557479/

CDC. (2021). STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/default.htm

Centers for Disease Control and Prevention. (2021, July 22). Chlamydial infections – STI treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm

Cyr, S. S. (2020). Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(50). https://doi.org/10.15585/mmwr.mm6950a6

Garcia, M. R., & Wray, A. A. (2024, April 20). Sexually Transmitted Infections. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560808/

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Patient Setting:

28-year–old female presents to the clinic with a 2 day history of frequency,burningand pain uponurination;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 startedapproximately 2 days ago; also experiencingsevere lower abdominal pain and noted brown foulssmelling 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 3children.
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 SI and S2.
Chest: WNL
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL
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

SOAP Note Assignment

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.

Format
• Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be no longer than 3–
4 pages excluding the title and the references and in 12pt font