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.
PMH/Medical/Surgical History
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.
Objective Data
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: 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
- A56.01 “Chlamydial cystitis and urethritis” (2018). Those symptoms that are mentioned by the patient are similar to the signs of cystitis that is why it is likely to be observed in the JD’s case. The woman urinates rather often. Moreover, she suffers from painful and burning sensations during this process. The color of her urine is dark and it smells foul. In this way, it may be affected by the presence of blood. In addition to that, JD has abdominal pain for a while, which is familiar for the discussed health issue. Even though cystitis seems to have serious symptoms, many women are diagnosed with it. This infection of the bladder is common and usual. It is typically caused by indecent toilet hygiene and pregnancy. Cystitis can be obtained during the hospital stay because of the use of the catheter. The patient is likely to suffer from this issue since her sexual activity increased and she experiences chlamydia for the second time.
- A54.03 “Gonococcal cervicitis, unspecified” (2018). The patient’s cervix can be inflamed due to a wide range of different causes. It can be triggered by a simple allergic reaction, for instance. However, in the majority of cases, the adverse influence of some infection is to blame. JD is likely to suffer from gonorrhea that is typically identified in half of the female population, which proves its frequency. Taking into consideration the fact that the patient reveals that she has problems with discharge, this diagnosis may suit her.
- Z87.440 “Personal history of urinary (tract) infections” (2018). According to the previous medical history of the patient, she has already suffered from gonorrhea two times and once from chlamydia. As UTIs are not new to her, she may experience them one more time. In particular, she could have got bacteria while having sex with her partner. The selected diagnosis seems to be appropriate because its signs are similar to JD’s symptoms. For instance, she suffers from pain and burning associated with increased discharge.
Plan of Care
UTIs can affect both male and female populations, but they are more common for women than for men due to their anatomical characteristics. The risk of having this kind of issue increases because of the vulnerability of organs. According to Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook (2016), this problem can affect women of all ages that is why they are under a constant threat of acquiring UTIs. In this way, it is significant to ensure that healthcare professionals can develop a correct diagnosis. It is not enough for them to treat the identified diseases; previous and recurrent problems should also be considered.
- Chlamydial cystitis and urethritis. From the very beginning, a healthcare professional should develop a diagnosis to start treating the patient and improving one’s health. Taking into consideration the case of JD, for instance, it is significant to ensure that her complaints are aligned with the major symptoms of chlamydial cystitis. It is advantageous to start with the urine test because it allows revealing whether the corresponding bacteria is present. At the same time, it is significant to examine the patient’s blood. The results of this test can identify the presence of inflammation. Medical treatment should be recommended further. In particular, the prescription of antibiotics is required. Among the most common options are amoxicillin or azithromycin. It is enough to take them once to overcome this issue. Patient education is also required. The woman should be aware of the peculiarities of her condition so that she can implement preventive measures in the future. Hence, she should pay attention to toilet hygiene. Urination discharge after intercourse is recommended as well as a regular intake of antibiotics as a preventive measure.
- Gonococcal cervicitis. If a healthcare professional conducts a physical examination of the patient and notices that her cervix is inflamed, this diagnosis should be made. To ensure its correctness, additional examination of blood and urine can be beneficial. These tests allow finding out if the infection is present and what exactly caused the disease. Medical treatment that is based on the intake of antibiotics is recommended in this case. A single dose of doxycycline can be enough to facilitate the client’s recovery. If this kind of treatment turns out to be ineffective, there is an option of using cryo- or laser therapy. Patient education should focus on the limitations associated with sexual activities.
- Personal history of URIs. This diagnosis can be made if inflammation is identified due to the results of the blood and urine tests. Moreover, a particular infection can be detected, which simplifies treatment that includes antibiotics. For instance, it is possible to offer the patient to start with trimethoprim. Some complications may be observed during the treatment process because JD has already experienced a similar type of treatment earlier. As a result, she may face resistance to some drugs. This problem can be overcome if professionals focus on their condition and its changes, which allows identifying if selected medication is appropriate. Patient education, in its turn, needs to deal with taking alkaline substances. It is also beneficial to drink large amounts of water. Unfortunately, the treatment of this problem may last for about 6 months.
References
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.