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. 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 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 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. 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

The focus is on different patient presentations and processes for determining diagnosis, including laboratory tests, diagnostic tests, physical findings, screening for possible misuse and abuse of controlled substances, red flags, appropriate time for referrals, appropriate prescriptions, and follow-up. Select a chronic or acute pain patient treated during your preceptorship whose condition or compliance with the treatment plan was particularly challenging and involved the prescription of Schedule II controlled substances. 40 yr old male with PMH of bi polar disorder, DM, ETOH abuse, and drug abuse( cocaine). While drinking patient crashed a motorized bicycle with bike petal impaling left lower leg. Presents with pain 9/10 large laceration 5inx2inx2in smells of alcohol and blood shot eyes. Analyze the patient’s overall social and medical history, clinical symptoms, and clinical assessment in the context of the disease state based on relevant literature. Develop a 20- to 30-minute Microsoft® PowerPoint® presentation, with detailed speaker notes, on the clinical management of the selected patient. Identify the relationship of the natural history of illness, disease or injury, pathophysiology, and symptomatology to pharmacotherapeutic agents commonly used to treat patients with conditions requiring the use of Schedule II controlled substances. Assess the risk of addiction associated with the use of Schedule II controlled substances utilizing 1 of the risk assessment tools. Evaluate the diagnostic work-up and clinical findings, including a rationale for each diagnostic test and expected findings, and recommend a diagnosis based on clinical and diagnostic findings. Develop the plan of care, including modifications of proposed therapy and dosages based on history of substance abuse or end-of-life considerations. Include a Schedule II controlled medication; provide a written prescription that contains all relevant components appropriate for the Schedule II controlled substance. (For California, the prescription writing for Schedule II through V must be consistent with Health and Safety Code and Pharmacy law.) Include any assistive therapies and specific limitations of activities. Address any age-appropriate modifications of proposed therapy or dosage modifications. Analyze the potential complications of care, drug interactions, and potential side effects of medication. Describe ethical and legal standards and ramifications of prescribing controlled substances. Consider the following in your discussion: Pharmacy monitoring programs Treatment addiction centers NP scope of practice in addiction rehab Medication-assisted therapies Create a patient education plan that shows understanding of the patient’s developmental age, health literacy, socioeconomic status, cultural sensitivity, and health belief models. Include underlying health issues, the proposed plan of care, and possible side effects or complications. Demonstrate how patient/family engagement in the plan of care will be observed. Provide examples of how the principles of Watson’s Theory of Human Caring are integrated into the plan of care and patient education. Analyze the challenges that this patient presented to you and how this impacted your growth as a professional nurse practitioner