[Solved] outline draft

Assignment Prompt & Instructions

– ## NPW.casestudy.docx

– NURS101L-FitzClinicalJudgmentPlanSample1.pdf

**## NPW.casestudy.docx**

**Comprehensive UTI (Urinary Tract Infection) Case Study**

**Patient Chart**

**Patient Name:** Mary Elizabeth James

**Date of Birth:** 02/09/1968

**Age:** 57

**Gender:** Female

**Medical Record Number:** 20250316

**Date of Admission:** 03/16/2025

**Primary Care Provider:** Dr. Susan Miller

**Chief Complaint (CC)**

_"I’ve had painful urination and frequent urges to go to the bathroom for the last two days."_

**History of Present Illness (HPI)**

Mary James is a 57-year-old female who presents with complaints of dysuria (painful urination), urinary frequency, and urgency. These symptoms have been present for the past 48 hours and have progressively worsened. She describes a burning sensation during urination, as well as the feeling of needing to urinate frequently, with only small amounts of urine being passed each time. She also notes mild lower abdominal discomfort but denies fever, chills, or hematuria.

**Past Medical History (PMH)**

·
**Recurrent Urinary Tract Infections (UTIs)** – several episodes over the last 5 years

·

·

·

·
**No known history of kidney stones or bladder conditions.**

**Surgeries & Procedures**

·

·

**Allergies**

·
**Penicillin** – Rash

**Medications**

· Metformin 1000 mg twice daily for type 2 diabetes

· Lisinopril 10 mg daily for hypertension

· Ibuprofen 200 mg as needed for osteoarthritis pain

**Family History (FH)**

·
**Father:** Deceased, 75, with a history of heart disease and hypertension

·
**Mother:** Alive, 82, with a history of hypertension and type 2 diabetes

·
**Sister:** Alive, 59, with a history of breast cancer

·
**Paternal Grandmother:** Died of complications from diabetes at age 80

**Social History (SH)**

·
**Smoking:** Non-smoker

·
**Alcohol:** Occasional drinker (1-2 drinks per week)

·
**Drug Use:** Denies illicit drug use

·
**Occupation:** Retired school teacher

·
**Living Situation:** Lives with her husband, independent in activities of daily living

**Review of Systems (ROS)**

·
**General:** No fever or weight loss

·
**Cardiovascular:** No chest pain, palpitations, or dizziness

·
**Respiratory:** No shortness of breath or cough

·
**Gastrointestinal:** No nausea, vomiting, or abdominal pain

·
**Genitourinary:** Dysuria, urinary frequency, and urgency, no hematuria

·
**Neurological:** No headaches or visual changes

·
**Musculoskeletal:** Mild joint pain due to osteoarthritis, no new symptoms

**Physical Assessment Findings**

**Vital Signs:**

· Temperature: 98.5°F (36.9°C)

· Heart Rate: 78 bpm, regular

· Respiratory Rate: 16 breaths/min

· Blood Pressure: 128/80 mmHg

· Oxygen Saturation: 98% on room air

**General Appearance:** Overweight female, alert and oriented, appears slightly uncomfortable due to dysuria

**Cardiovascular:** Regular rate and rhythm, no murmurs or gallops

**Respiratory:** Clear to auscultation bilaterally, no wheezing or crackles

**Abdomen:** Soft, non-tender, no hepatosplenomegaly, mild lower abdominal discomfort

**Genitourinary:** Positive for suprapubic tenderness, no external genital lesions, no costovertebral angle tenderness

**Neurological:** Alert and oriented, no focal deficits

**Laboratory Results**

Urinalysis

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Appearance | Cloudy | Clear |
| Color | Yellow | Pale yellow to amber |
| pH | 7.0 | 4.5-8.0 |
| Protein | Negative | Negative |
| Glucose | Negative | Negative |
| Ketones | Negative | Negative |
| Blood | Negative | Negative |
| Leukocyte Esterase | Positive (+) | Negative |
| Nitrites | Positive (+) | Negative |
| Specific Gravity | 1.015 | 1.005-1.030 |
| Bacteria | Present | Negative |

Complete Blood Count (CBC)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| White Blood Cell Count (WBC) | 9.0 x10³/µL | 4.0-11.0 x10³/µL |
| Hemoglobin (Hgb) | 13.5 g/dL | 12.0-16.0 g/dL |
| Hematocrit (Hct) | 41% | 36-46% |
| Platelets (Plt) | 250 x10³/µL | 150-450 x10³/µL |

Basic Metabolic Panel (BMP)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Sodium (Na) | 138 mEq/L | 135-145 mEq/L |
| Potassium (K) | 4.1 mEq/L | 3.5-5.1 mEq/L |
| Chloride (Cl) | 104 mEq/L | 98-107 mEq/L |
| Bicarbonate (HCO₃) | 24 mEq/L | 22-28 mEq/L |
| Blood Urea Nitrogen (BUN) | 12 mg/dL | 7-20 mg/dL |
| Creatinine (Cr) | 0.8 mg/dL | 0.6-1.2 mg/dL |
| Glucose (fasting) | 96 mg/dL | 70-99 mg/dL |

Urine Culture & Sensitivity

·
**Organism:** Escherichia coli (E. coli)

·
**Antibiotic Sensitivities:**

· Amoxicillin: Sensitive

· Trimethoprim-Sulfamethoxazole (Bactrim): Resistant

· Nitrofurantoin: Sensitive

· Ciprofloxacin: Sensitive

© 2025 NotesPRN. All rights reserved.

**NURS101L-FitzClinicalJudgmentPlanSample1.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nurs101l-fitzclinicaljudgmentplansample1-pdf)

**NURS101L-FitzClinicalJudgmentPlanSample1.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nurs101l-fitzclinicaljudgmentplansample1-pdf)

**## NPW.casestudy.docx**

**Comprehensive UTI (Urinary Tract Infection) Case Study**

**Patient Chart**

**Patient Name:** Mary Elizabeth James

**Date of Birth:** 02/09/1968

**Age:** 57

**Gender:** Female

**Medical Record Number:** 20250316

**Date of Admission:** 03/16/2025

**Primary Care Provider:** Dr. Susan Miller

**Chief Complaint (CC)**

_"I’ve had painful urination and frequent urges to go to the bathroom for the last two days."_

**History of Present Illness (HPI)**

Mary James is a 57-year-old female who presents with complaints of dysuria (painful urination), urinary frequency, and urgency. These symptoms have been present for the past 48 hours and have progressively worsened. She describes a burning sensation during urination, as well as the feeling of needing to urinate frequently, with only small amounts of urine being passed each time. She also notes mild lower abdominal discomfort but denies fever, chills, or hematuria.

**Past Medical History (PMH)**

·
**Recurrent Urinary Tract Infections (UTIs)** – several episodes over the last 5 years

·

·

·

·
**No known history of kidney stones or bladder conditions.**

**Surgeries & Procedures**

·

·

**Allergies**

·
**Penicillin** – Rash

**Medications**

· Metformin 1000 mg twice daily for type 2 diabetes

· Lisinopril 10 mg daily for hypertension

· Ibuprofen 200 mg as needed for osteoarthritis pain

**Family History (FH)**

·
**Father:** Deceased, 75, with a history of heart disease and hypertension

·
**Mother:** Alive, 82, with a history of hypertension and type 2 diabetes

·
**Sister:** Alive, 59, with a history of breast cancer

·
**Paternal Grandmother:** Died of complications from diabetes at age 80

**Social History (SH)**

·
**Smoking:** Non-smoker

·
**Alcohol:** Occasional drinker (1-2 drinks per week)

·
**Drug Use:** Denies illicit drug use

·
**Occupation:** Retired school teacher

·
**Living Situation:** Lives with her husband, independent in activities of daily living

**Review of Systems (ROS)**

·
**General:** No fever or weight loss

·
**Cardiovascular:** No chest pain, palpitations, or dizziness

·
**Respiratory:** No shortness of breath or cough

·
**Gastrointestinal:** No nausea, vomiting, or abdominal pain

·
**Genitourinary:** Dysuria, urinary frequency, and urgency, no hematuria

·
**Neurological:** No headaches or visual changes

·
**Musculoskeletal:** Mild joint pain due to osteoarthritis, no new symptoms

**Physical Assessment Findings**

**Vital Signs:**

· Temperature: 98.5°F (36.9°C)

· Heart Rate: 78 bpm, regular

· Respiratory Rate: 16 breaths/min

· Blood Pressure: 128/80 mmHg

· Oxygen Saturation: 98% on room air

**General Appearance:** Overweight female, alert and oriented, appears slightly uncomfortable due to dysuria

**Cardiovascular:** Regular rate and rhythm, no murmurs or gallops

**Respiratory:** Clear to auscultation bilaterally, no wheezing or crackles

**Abdomen:** Soft, non-tender, no hepatosplenomegaly, mild lower abdominal discomfort

**Genitourinary:** Positive for suprapubic tenderness, no external genital lesions, no costovertebral angle tenderness

**Neurological:** Alert and oriented, no focal deficits

**Laboratory Results**

Urinalysis

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Appearance | Cloudy | Clear |
| Color | Yellow | Pale yellow to amber |
| pH | 7.0 | 4.5-8.0 |
| Protein | Negative | Negative |
| Glucose | Negative | Negative |
| Ketones | Negative | Negative |
| Blood | Negative | Negative |
| Leukocyte Esterase | Positive (+) | Negative |
| Nitrites | Positive (+) | Negative |
| Specific Gravity | 1.015 | 1.005-1.030 |
| Bacteria | Present | Negative |

Complete Blood Count (CBC)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| White Blood Cell Count (WBC) | 9.0 x10³/µL | 4.0-11.0 x10³/µL |
| Hemoglobin (Hgb) | 13.5 g/dL | 12.0-16.0 g/dL |
| Hematocrit (Hct) | 41% | 36-46% |
| Platelets (Plt) | 250 x10³/µL | 150-450 x10³/µL |

Basic Metabolic Panel (BMP)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Sodium (Na) | 138 mEq/L | 135-145 mEq/L |
| Potassium (K) | 4.1 mEq/L | 3.5-5.1 mEq/L |
| Chloride (Cl) | 104 mEq/L | 98-107 mEq/L |
| Bicarbonate (HCO₃) | 24 mEq/L | 22-28 mEq/L |
| Blood Urea Nitrogen (BUN) | 12 mg/dL | 7-20 mg/dL |
| Creatinine (Cr) | 0.8 mg/dL | 0.6-1.2 mg/dL |
| Glucose (fasting) | 96 mg/dL | 70-99 mg/dL |

Urine Culture & Sensitivity

·
**Organism:** Escherichia coli (E. coli)

·
**Antibiotic Sensitivities:**

· Amoxicillin: Sensitive

· Trimethoprim-Sulfamethoxazole (Bactrim): Resistant

· Nitrofurantoin: Sensitive

· Ciprofloxacin: Sensitive

© 2025 NotesPRN. All rights reserved.

**NURS101L-FitzClinicalJudgmentPlanSample1.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nurs101l-fitzclinicaljudgmentplansample1-pdf)

**## NPW.casestudy.docx**

**Comprehensive UTI (Urinary Tract Infection) Case Study**

**Patient Chart**

**Patient Name:** Mary Elizabeth James

**Date of Birth:** 02/09/1968

**Age:** 57

**Gender:** Female

**Medical Record Number:** 20250316

**Date of Admission:** 03/16/2025

**Primary Care Provider:** Dr. Susan Miller

**Chief Complaint (CC)**

_"I’ve had painful urination and frequent urges to go to the bathroom for the last two days."_

**History of Present Illness (HPI)**

Mary James is a 57-year-old female who presents with complaints of dysuria (painful urination), urinary frequency, and urgency. These symptoms have been present for the past 48 hours and have progressively worsened. She describes a burning sensation during urination, as well as the feeling of needing to urinate frequently, with only small amounts of urine being passed each time. She also notes mild lower abdominal discomfort but denies fever, chills, or hematuria.

**Past Medical History (PMH)**

·
**Recurrent Urinary Tract Infections (UTIs)** – several episodes over the last 5 years

·

·

·

·
**No known history of kidney stones or bladder conditions.**

**Surgeries & Procedures**

·

·

**Allergies**

·
**Penicillin** – Rash

**Medications**

· Metformin 1000 mg twice daily for type 2 diabetes

· Lisinopril 10 mg daily for hypertension

· Ibuprofen 200 mg as needed for osteoarthritis pain

**Family History (FH)**

·
**Father:** Deceased, 75, with a history of heart disease and hypertension

·
**Mother:** Alive, 82, with a history of hypertension and type 2 diabetes

·
**Sister:** Alive, 59, with a history of breast cancer

·
**Paternal Grandmother:** Died of complications from diabetes at age 80

**Social History (SH)**

·
**Smoking:** Non-smoker

·
**Alcohol:** Occasional drinker (1-2 drinks per week)

·
**Drug Use:** Denies illicit drug use

·
**Occupation:** Retired school teacher

·
**Living Situation:** Lives with her husband, independent in activities of daily living

**Review of Systems (ROS)**

·
**General:** No fever or weight loss

·
**Cardiovascular:** No chest pain, palpitations, or dizziness

·
**Respiratory:** No shortness of breath or cough

·
**Gastrointestinal:** No nausea, vomiting, or abdominal pain

·
**Genitourinary:** Dysuria, urinary frequency, and urgency, no hematuria

·
**Neurological:** No headaches or visual changes

·
**Musculoskeletal:** Mild joint pain due to osteoarthritis, no new symptoms

**Physical Assessment Findings**

**Vital Signs:**

· Temperature: 98.5°F (36.9°C)

· Heart Rate: 78 bpm, regular

· Respiratory Rate: 16 breaths/min

· Blood Pressure: 128/80 mmHg

· Oxygen Saturation: 98% on room air

**General Appearance:** Overweight female, alert and oriented, appears slightly uncomfortable due to dysuria

**Cardiovascular:** Regular rate and rhythm, no murmurs or gallops

**Respiratory:** Clear to auscultation bilaterally, no wheezing or crackles

**Abdomen:** Soft, non-tender, no hepatosplenomegaly, mild lower abdominal discomfort

**Genitourinary:** Positive for suprapubic tenderness, no external genital lesions, no costovertebral angle tenderness

**Neurological:** Alert and oriented, no focal deficits

**Laboratory Results**

Urinalysis

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Appearance | Cloudy | Clear |
| Color | Yellow | Pale yellow to amber |
| pH | 7.0 | 4.5-8.0 |
| Protein | Negative | Negative |
| Glucose | Negative | Negative |
| Ketones | Negative | Negative |
| Blood | Negative | Negative |
| Leukocyte Esterase | Positive (+) | Negative |
| Nitrites | Positive (+) | Negative |
| Specific Gravity | 1.015 | 1.005-1.030 |
| Bacteria | Present | Negative |

Complete Blood Count (CBC)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| White Blood Cell Count (WBC) | 9.0 x10³/µL | 4.0-11.0 x10³/µL |
| Hemoglobin (Hgb) | 13.5 g/dL | 12.0-16.0 g/dL |
| Hematocrit (Hct) | 41% | 36-46% |
| Platelets (Plt) | 250 x10³/µL | 150-450 x10³/µL |

Basic Metabolic Panel (BMP)

| | | |
| — | — | — |
| **Test** | **Result** | **Reference Range** |
| Sodium (Na) | 138 mEq/L | 135-145 mEq/L |
| Potassium (K) | 4.1 mEq/L | 3.5-5.1 mEq/L |
| Chloride (Cl) | 104 mEq/L | 98-107 mEq/L |
| Bicarbonate (HCO₃) | 24 mEq/L | 22-28 mEq/L |
| Blood Urea Nitrogen (BUN) | 12 mg/dL | 7-20 mg/dL |
| Creatinine (Cr) | 0.8 mg/dL | 0.6-1.2 mg/dL |
| Glucose (fasting) | 96 mg/dL | 70-99 mg/dL |

Urine Culture & Sensitivity

·
**Organism:** Escherichia coli (E. coli)

·
**Antibiotic Sensitivities:**

· Amoxicillin: Sensitive

· Trimethoprim-Sulfamethoxazole (Bactrim): Resistant

· Nitrofurantoin: Sensitive

· Ciprofloxacin: Sensitive

© 2025 NotesPRN. All rights reserved.

**NURS101L-FitzClinicalJudgmentPlanSample1.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/nurs101l-fitzclinicaljudgmentplansample1-pdf)

– 1
– 2