Subjective Data: The patient is a 28-year-old woman who presents with frequency and pain upon voiding during the last two days. Over the past week the patient has been experiencing intense burning lower abdominal pain and vaginal discharge, which may be a sign of suppurative inflammation.
Chief Compliant: Increased burning pain upon urination and severe pain in the lower part of the stomach. The symptoms which started recently are similar to those of previous Urinary Tract Infections (UTIs). After having unprotected intercourse with her former partner, she noted foul-smelling vaginal discharge of brown color.
History of Present Illness
Onset of the event: The patient noticed the dark color of urine and brownish smelling vaginal discharge after unprotected intercourse with her former partner.
Provocation or palliation: The patient experiences pain upon urination.
Quality of the pain: The patient describes the pain as severe; the pain is frequent as it follows voiding.
Region and Radiation: The pain is located in the lower abdominal area and pelvic area upon voiding. The patient gives no information about extending or changing of the pain location.
Severity: The patient describes the pain as burning; she denies breast discharge and confirms last pap 6 months ago.
Time (history): The first symptoms of lower abdominal pain appeared one week ago; pain upon urination appeared two days ago. The pain is described by the patient as increased and frequent.
PMH/Medical/Surgical History: The patient has not been taking any medicine; her allergies include Trimethoprim (TOM)/ Sulfamethoxazole (SMX) with rash reaction. The patient has a history of UTI (this year she came through the infection three times). Other major medical issues included gonorrhea (X2), chlamydia (X1), Gravida IV Para III. The patient gives no information about immunization, injuries and hospitalizations; surgeries included tubal ligation two years ago. There is no information about possible psychiatric problems of the patient. She has been pregnant four times with three children reaching the viable gestational age. She also confirms having multiple former sexual partners; at the moment, she has a new sexual partner.
Significant Family History: The patient does not specify any significant inheritable diseases found among her relatives.
Social History: The patient is a single woman in moderate distress; she denies alcohol, smoking and use of drugs. At the moment, she lives with her new partner and three children.
Review of Symptoms
- General: WNL;
- Integumentary: WNL;
- Head: WNL;
- Eyes: WNL;
- ENT: WNL;
- Respiratory: WNL;
- Gastrointestinal: WNL;
- Genitourinary: Positive for frequency, burning and pain upon urination; positive for brown foul-smelling vaginal discharge; denies breast discharge;
- Musculoskeletal: WNL;
- Neurological: WNL;
- Endocrine: WNL;
- Hematologic: WNL;
- Psychologic: WNL.
- Objective Data:
- Vital Signs: BP – 100/80; HR – 80; RR – 16; T – 99.7 F; Wt – 120; Ht – 5’ 0”.
Physical Assessment Findings
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage.
Rectal: 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.
Assessment
- Diagnosis 1 – Neisseria gonorrhoeae (A54.9): the final diagnosis is chosen according to laboratory and diagnostic testing (as vaginal discharge culture includes Neisseria gonorrhoeae) as well as subjective data reported by the patient.
- Diagnosis 2 – Chlamydia (A74.9): the diagnosis is chosen due to positive monoclonal AB for Chlamydia.
- Diagnosis 3 – Complicated Urinary Tract Infection (N39.0). The following diagnosis is selected due to several factors: gram negative rods, recurring UTIs and Sexually Transmitted Infections (STIs) such as gonorrhea and chlamydia; the symptoms such as lower abdominal pain and brown vaginal discharge.
Plan of care
Neisseria gonorrhoeae: It is recommended to take 250 mg of Ceftriaxone intramuscularly and 1 g of Azithromycin orally (Lebwohl, Heymann, Berth-Jones, & Coulson, 2017). The alternative recommended option is 400 mg of Cefixime orally in addition to Azithromycin dose mentioned above (March, 2018). Prevention measures include examining health conditions of the patient’s partners, as there is a high risk of the infection transmitting from one individual to another.
Chlamydia: Treatment includes taking 1 g of Azithromycin orally; alternative treatment is 500 mg of Amoxicillin three times a day orally for 7 days (March, 2018). Different recommended option is 100 mg of Doxycycline twice a day orally for 7 days (March, 2018). It is highly recommended to use condoms regularly and appropriately in order to prevent the spread of the disease. It is also important to mind possible risks of unsafe sexual practices and the positive consequences of timely STI tests.
Complicated Urinary Tract Infection: The treatment of UTI is based on antibiotics; the recommended prescription is 500 mg of Ciprofloxacin twice a day orally for 7 days. Prevention measures to decrease the frequency of complicated UTI include practicing proper hygiene (especially after urinating or defecating) and choosing underwear made of appropriate materials. It is also recommended to urinate within a short period of time after intercourse and void frequently; increased fluid intake is also prescribed for UTI prevention.
References
Lebwohl, M.G., Heymann, W. R., Berth-Jones, J., Coulson, I. (Eds.). (2017). Treatment of Skin Disease E-Book: Comprehensive Therapeutic Strategies. China: Elsevier Health Sciences.
March, A.L. (Ed.). (2018). Women’s Health Across the Lifespan, An Issue of Nursing Clinics, E-Book. Philadelphia, PA: Elsevier Health Sciences.