Patient Initials: N/A (a 28-year-old woman)
Subjective Data: Frequent and burning pain during urination (during the last two days), increased lower abdominal and vaginal discharge (during the last week).
Chief Complaint: “a 2-day history of frequency, burning, and pain upon urination”.
History of Present Illness: An unprotected intercourse with a former boyfriend results in severe lower abdominal pain and brown foul-smelling discharge and urinary symptoms of UTIs.
PMH/Medical/Surgical History: Recurrent UTIs (three times in this year), gonorrhea (twice), Chlamydia (once), G4:P3. Medication: Trimethoprim/Sulfamethoxazole (past) and no current medication. Surgery: tubal ligation (two years ago).
Significant Family History: Single. Sex with multiple male partners. At this moment, the patient lives with 3 children and a new boyfriend.
Social History: no smoking, alcohol, and drug use
Review of Symptoms:
General: the patient is in moderate distress; Integumentary: n/a; Head, Eyes, and ENT: within normal limits; Cardiovascular: Regular rate and rhythm; Respiratory: n/a; Gastrointestinal: soft, tender, with increased suprapubic tenderness; Genitourinary: cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage; Musculoskeletal: within normal limits; Neurological: within normal limits; Endocrine: n/a; Hematologic: n/a; Psychologic: n/a.
Objective Data:
Vital Signs: BP – 100/80; P 80; R 16; T 99.7; Wt. 120; Ht. 50; BMI: 23.4 (normal).
Physical Assessment Findings:
HEENT: WNL
Lymph Nodes: n/a
Carotids: n/a
Lungs: clear
Heart: normal
Abdomen: soft, tender, with increased suprapubic tenderness
Genital/Pelvic: cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage
Rectum: WNL
Extremities/Pulses: WNL
Neurologic: WNL
Laboratory and Diagnostic Test Results:
LKC Differential: Neutrophils: 68% (higher than normal), bands: 7% (higher than normal), lymphs: 13% (lower than normal), monos: 8% (normal), EOS: 2% (normal);
Urine: straw colored (it is a healthy color); sp gr: 1.015 (normal value), pH: 8.0 (normal value); protein: negative (normal), glucose: negative (normal); ketones: negative (normal), bacteria: many (the presence of some bacteria in the body is abnormal); lkcs: 10-15 (abnormal as it is higher than a normal level); RBC: 0-1 (a normal value).
Gram-negative rods (it is abnormal as it signalizes about the presence of bacteria in urine).
Vaginal discharge culture is generally abnormal because of the presence of several bacteria: gram-negative diplococci, Neisseria gonorrhea; sensitives pending; positive monoclonal AB (Chlamydia), KOH preparation; WET preparation; VDRL negative.
Assessment:
Taking into consideration the results of the laboratory and diagnostic tests, physical examination, and personal complaints of the patient, several diagnoses can be given at this moment in the order of their possible priority:
Gonorrhea or gonococcal infection, unspecified (A54.9) – the presence of a specific bacterium in a urine culture;
Chlamydia or chlamydial infection, unspecified (A74.9) – the presence of a specific bacterium in a urine culture;
Female pelvic inflammatory disease, unspecified (N73.9) – the laboratory confirmation of cervical infection with the laboratory tests (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017);
Unspecified sexually transmitted disease (A64) – the patient suffers from dysuria, high temperature, and pain, and STIs may be one of the possible causes of this problem (Frobenius & Bogdan, 2015);
Urinary tract infection, site not specified (N39.0) – its possibility may be explained by frequent and painful urination, the past UTI history, and a negative vaginal discharge culture defined through the laboratory tests (Michels & Sands, 2015).
Plan of Care:
Gonorrhea. This diagnosis can be proved through urine tests and a swab of an affected area. Antibiotics turn out to be one of the best and most effective treatment methods for this disease. Levofloxacin or ciprofloxacin can be offered (Buttaro et al., 2017). They are usually taken orally during 7-10 days but may be given in the form of an injection. Education for patients includes prevention of unsafe sex, the establishment of long-term relationships, and communication with a healthcare provider. Further counseling may be promoted through cooperation with a local therapist and a gynecologist.
Chlamydia. Similar to gonorrhea diagnostic tests, urine testing and swabbing is required. Taking such antibiotics as azithromycin (500 mg daily) or doxycycline (100 mg every 12 hours for ten days) is an appropriate treatment for patients (Buttaro et al., 2017). Regular urine tests and counseling with a gynecologist every three months are the example of patient education to cover the nature of the disease, its transmission, and risks.
Female pelvic inflammatory disease. To diagnose this disease, it is necessary to take blood and urine tests and take an ultrasound to check the condition of the reproductive organs. In serious cases, the patient is offered a laparoscopy. Treatment should be offered to both sexual partners and based on such antibiotics as metronidazole (500 mg twice per day during 7 days) or ofloxacin (200 mg twice per day during 3-5 days) (Buttaro et al., 2017). The patient should be educated about the importance of vitamins, protected sex, and regular testing. Counseling with a therapist and a gynecologist is required.
Unspecified sexually transmitted disease. The diagnosis of these diseases includes blood/urine/fluid tests to confirm the presence/absence of bacteria. Antibiotics can be assigned regarding the nature and scope of the disease and its possible complications (Buttaro et al., 2017). Both sexual partners should be educated about the importance of safe sex, regular tests, and trust in relationships. Counseling with a gynecologist, a family therapist, and a psychologist can be rather helpful.
Urinary tract infection. Urine samples and lab analysis are required to diagnose this disease. A computerized tomography may be used to observe changes in the urinary tract. Trimethoprim/Sulfamethoxazole may be recommended as a part of treatment (in case it was effective in the past). Oral therapy may include ceftriaxone or erythromycin (Buttaro et al., 2017). Due to the history of this disease, the patient should be educated about the main risk groups and preventive methods like hygiene, safe sexual intercourses, and healthy eating. Counseling with a therapist and a gynecologist should be followed.
References
Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.
Frobenius, W., & Bogdan, C. (2015). Diagnostic value of vaginal discharge, wet mount and vaginal pH – An update on the basics of gynecologic infectiology. Geburtshilfe und Frauenheilkunde, 75(4), 355-366.
Michels, T.C., & Sands, J.E. (2015). Dysuria: Evaluation and differential diagnosis in adults. American Family Physician, 92(9), 778-788.