Introduction
Urinary tract infections (UTIs) are observed in women more often than in men because of their anatomical peculiarities. Moreover, patients tend to pay not enough attention to these issues, as they often have similar symptoms. Thinking that they have an ordinary case of cystitis, they can overlook gonorrhea or chlamydia (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). That is why healthcare professionals need to differentiate these diseases and make a diagnosis in time to prevent the possibility of further complications.
Subjective Data
- Current medical problem: 28-year-old female presents to the clinic with a 2-day history of frequency, burning, and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week.
- Chief complaint: burning and pain upon urination, lower abdominal pain, and vaginal discharge.
- History of present illness: complains of urinary symptoms similar to those of previous 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.
- Current medications: None. Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash ROS Last pap 6 months ago.
- Past medical history: Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
- Family history: Single; the history of multiple male sexual partners; currently lives with a new boyfriend and 3 children. Denies smoking, alcohol, and drug use.
- Review of systems: Denies breast discharge. Positive for urine looking dark. Frequent burning pain with urination. Abdominal pain. Vaginal discharge.
Objective Data
- Physical examination: 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, increased suprapubic tenderness. GU: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage. Rectal: WNL. EXT: WNL. NEURO: WNL
- Laboratory and diagnostic testing results: Lkc differential: Neutrophils 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.
Assessment
- A56.01 Chlamydial cystitis and urethritis (ICD10 Data, 2017a). The patient experiences vaginal discharge. She suffers from the pain associated with urination and lower abdominal pain. She also has a fever, Gram-negative diplococci, and positive monoclonal AB. She is positive for Neisseria gonorrhea.
- N73.9 Female pelvic inflammatory disease, unspecified (ICD10 Data, 2017b). The patient experiences vaginal discharge and pain associated with urination and lower abdominal pain. Her urine is dark and foul-smelling. Gram-negative rods are observed.
- Z87.440 Personal history of urinary (tract) infections (ICD10 Data, 2017c). The patient experiences urinary frequency. She has pain and burning during urination. Her urine is dark and foul-smelling. She has abdominal pain.
Plan of Care
- Chlamydial cystitis and urethritis. Make diagnoses based on the interview, previous illnesses, and new lab tests. Provide a rationale for diagnosis. Educate the patient regarding the causes of the disease and its effects on the genital tract. Discuss the way it is spread and the possibility of experiencing no symptoms. Prescribe Azithromycin (1 g) or Doxycycline (200 mg/day) for a week (Buttaro et al., 2013). Discuss safe sex practices. Emphasize the necessity for a partner to have a test and receive treatment simultaneously. Appoint a subsequent visit and re-testing.
- Pelvic inflammatory disease. Make diagnoses based on the interview, previous illnesses, and new lab tests. Educate the patient regarding its causes, treatment, and prevention. Prescribe Ceftriaxone (250 mg), Doxycycline (100 mg/day), Metronidazole (500 mg/day) for two weeks. Educate the patient regarding risk behaviors and appoint a subsequent visit and re-testing (“Pelvic Inflammatory Disease,” 2015).
- Urinary (tract) infections. Make diagnoses based on the interview, previous illnesses, and new lab tests. Discuss the most frequently observed illnesses with the patient. Emphasize the vulnerability of the urinary tract. Point out how it can be affected and how to prevent it. Recommend increased fluid intake and vitamin C (100 mg/day), trimethoprim (160-800 mg) (Hickling & Nitti, 2013).
Evaluation of Priority Diagnosis
The patient is likely to have chlamydial urethritis because, in addition to the discussed physical symptoms, she has multiple partners and a previous history of sexually transmitted diseases. She should be treated by a physician who makes a diagnosis and a nurse who provides care. Consultation of a gynecologist is needed. Professionals should conduct lab tests. A pharmacologist is to provide medicines. The patient’s partners should also be tested for sexually transmitted diseases and treated.
Barriers to optimal disorder management and outcomes include partners’ resistance to be tested and treated, the absence of right diagnosis, allergy to drugs, absence of support, insurance issues. They can be overcome if the patient realizes the importance of treatment and threats of the disease and explains them to her partners. She should have a subsequent visit to change medication if needed and address social services if assistance is needed. Facilitators to positive outcomes include support from partners and relatives, good overall health condition, strict following of physician’s recommendations, and the absence of unprotected sex.
Conclusion
This assignment provides an opportunity to realize that women are at higher risk of having sexually transmitted diseases than men, which means that more attention should be paid to their treatment. Healthcare professionals should be able to differentiate the commonly observed diseases, their symptoms, and treatment, and educate their patients and other members of the community.
References
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care. Amsterdam, Netherlands: Elsevier.
Hickling, D., & Nitti, V. (2013). Management of recurrent urinary tract infections in healthy adult women. Reviews in Urology, 15(2), 41-48.
ICD10 Data. (2017a). Chlamydial cystitis and urethritis.Web.
ICD10 Data. (2017b).Female pelvic inflammatory disease, unspecified. Web.
ICD10 Data. (2017c).Personal history of urinary (tract) infections. Web.
Pelvic inflammatory disease (PID) and verified contact to PID treatment. (2015). Web.