Patient Initials: JD
Subjective Data: The woman is 28 years old. She is in moderate distress currently. The patient has suffered from complications during urination for two days already. She complains about its frequency and associated burning and pain. JD has suffered from increased abdominal pain for a week already as well as vaginal discharge. She started having issues with urinary tract infections (UTIs) about two days ago. The patient had unprotected intercourse with her boyfriend. It was entailed by noted brown foul-smelling discharge.
Chief Complaint: frequency, burning, and pain upon urination; increased lower abdominal pain and vaginal discharge.
History of Present Illness: reoccurring symptoms of UTIs that started two days ago. Abdominal pain and increased noted brown foul-smelling vaginal discharge.
The patient had a tubal ligation two years before this case. She had four pregnancies; during one of them, she failed to carry to term. She had three UTIs this year and suffered from gonorrhea X2 and chlamydia X1 previously. She does not take any drugs for UTIs currently but uses Trimethoprim/Sulfamethoxazole for her rash. Last pap was half a year ago. JD had several male partners but now she lives with her boyfriend.
Significant Family History: The patient has three children and a boyfriend.
Social History: The patient does not smoke, drink alcohol, and take drugs.
Review of Symptoms: Positive for dark urine; frequent, burning, and painful urination; abdominal pain; increased vaginal discharge. Denies breast discharge.
General: moderate distress; Head: denies; Eyes: denies; ENT: denies; Cardiovascular: regular rhythm, normal S1 and S2; Respiratory: clear to auscultation; Gastrointestinal: soft and tender abdomen, increased suprapubic tenderness; Genitourinary: positive for dark urine; frequent, burning and painful urination; abdominal pain; cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage; Musculoskeletal: denies; Neurological: denies; Endocrine: denies; Hematologic: denies; Psychologic: denies.
- Vital Signs: BP 100/80, HR 80, RR 16, T 99.7 F, Wt. 120, Ht. 5’ 0” BMI 23.4
- Physical Assessment Findings:
- Gen: Female in moderate distress.
- 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.
- EXT: WNL.
- NEURO: WNL.
Laboratory and Diagnostic
- Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
- UA: Straw 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
- A56.01 “Chlamydial cystitis and urethritis” (2018). JD is likely to have cystitis because its symptoms and signs are familiar with her complaints. In particular, she experiences burning and pain associated with frequent urination. Her urine is not neutral and has a foul smell. Moreover, it is dark, which may presuppose the presence of blood. The patient suffers from abdominal pain as well. This health condition is a usual infection of the bladder that is experienced by numerous women. Many of them get infected because of poor toilet hygiene, use of a catheter, and pregnancy. However, JD is likely to have this problem because she has already had Chlamydia and is now dealing with it for the second time. It is also possible that the frequency of her sexual activity increased when she started living with her boyfriend, which led to these consequences.
- A54.03 “Gonococcal cervicitis, unspecified” (2018). JD may suffer from the inflammation of the cervix that can be caused by various issues. Even though this disease can occur even because of an allergic reaction or reaction to a foreign body, it is usually associated with some infection. The patient, in particular, may be affected by gonorrhea. This disease is not rare and it affects 50% of all women. It can be diagnosed in JD, as the patient has issues with discharge.
- Z87.440 “Personal history of urinary (tract) infections” (2018). JD has already suffered from URIs according to her previous medical history. She has had gonorrhea X2 and chlamydia X1. JD’s URIs are likely to be caused by bacteria she got during sexual intercourse with one of her partners. In this way, they are expected to be community-acquired. This diagnosis suits the case because the patient’s symptoms are aligned with it. JD suffers from frequent and painful urination, increased discharge, and pain.
Plan of Care
Women tend to be a more vulnerable population when speaking about UTIs in comparison to men. Anatomical differences make females less protected and increase their risk of having associated issues. Professionals consider that half of all women in the world are at the lifetime risk for this problem (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2016). Thus, healthcare professionals need to be able to identify and diagnose UTIs. They are expected not just to start treating cystitis if its symptoms are the most apparent but also to focus on the previous and recurrent diseases of the urinary tract.
- Chlamydial cystitis and urethritis. Healthcare professional needs to diagnose cystitis to enhance their patient’s condition. In the described situation, the final decision should be made if those major symptoms and signs of a disease that are experienced by the patient are the same as chlamydial cystitis. Examination of urine is critical in this perspective because it reveals what bacteria is present in it. The presence of inflammation can be identified with the help of a blood test. Antibiotic treatment is needed to cope with this health issue. For instance, amoxicillin or azithromycin can be used; usually, a single dose is enough. Further, a care provider is to educate JD regarding her condition, paying attention to the preventive measures, such as proper toilet hygiene, intake of cranberry juice, and urination after intercourse. In addition to that, it may be advantageous to take antibiotics twice a year to prevent cystitis if it occurs regularly.
- Gonococcal cervicitis. Healthcare professional can diagnose this disease if he/she observes the cervix and notices that it is inflamed. In addition to that, it is advantageous to have blood and urine tests because they can reveal the presence of infection and identify the very cause of the disease. In the majority of cases, the use of antibiotics is enough to overcome this problem. JD should take one dose of Doxycycline, for instance. In addition to that, it is possible to refer to cryotherapy or laser therapy if medications do not work. The patient should also be educated regarding her condition and the necessity of having no sexual intercourse until they are permitted by a professional.
- Personal history of URIs. To make such a diagnosis, healthcare professionals should have enough information about the patient’s previous health condition. Her blood and urine should be tested for inflammation and the particular infection. Treatment options are likely to start with the use of antibiotics, such as trimethoprim. Unfortunately, taking into consideration the fact that JD has already suffered from URIs and treated them with the help of antibiotics, she may be resistant to particular antibiotics. That is why it will be vital for healthcare professionals to monitor her condition and ensure that the selected treatment is appropriate. The patient should be educated regarding the necessity to take alkaline substances and the way recurrent URIs are to be addressed. In particular, she should increase the amount of water intake and drink cranberry juice. Six months of antibiotic therapy may be needed if no improvements are observed.
Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2016). Primary care: A collaborative practice. Maryland Heights, MO: Mosby.
Chlamydial cystitis and urethritis. (2018). Web.
Gonococcal cervicitis, unspecified. (2018). Web.
Personal history of urinary (tract) infections. (2018). Web.