Genitourinary Case Study and Care Plan

Genitourinary Case Study


Patient Initials

__28-year-old Female

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Subjective Data:

28-year-old female presents to the clinic with history of burning pain upon urination, increased lower abdominal pain and vaginal discharge of the past week;


Chief Compliant

: complaints of urinary symptoms similar to those of previous UTIs started two days ago also complains of severe lower abdominal pain and follow smelling brown discharge’


History of Present Illness:

the patient complains of urinary symptoms like those of previous urinary tract infection. started two days ago; patient is also experiencing severe lower abdominal pain is noted to have Brown foul smelling discharge, following of unprotective intercourse with her boyfriend.


PMH

UTIs, patient has three this year, gonorrhea x 2, chlamydia times x1 Gravida IV III


Medical/Surgical History:

the patient reports tubal ligation two years ago


Significant Family History:

none


Social History

:   pt is single with multiple sexual partners. Patient has three children, denies smoking alcohol or drug use.


Medication history:

patient does not have any current prescriptions, allergic to Trimethoprim and Sulfamethoxazole(rash) last pap was six months ago, denies breast discharge, positive for urine looking dark


Objective Data:


Vital Signs:



BP




100/80


HR 80


RR 16


Temp 99.7


WT 120


HT 5 feet


Physical Exam


Review of Symptoms (ROS) findings


General:

female moderate distress


HEENT PERRLA

, WNL


Cardiovascular Regular

rate and rhythm, normal S1 and S2


Chest

WNL


Respiratory

clear to auscultation


Abdominal

, soft, tender, increased suprapubic tenderness


Genitourinary:

cervical motion tenderness, adnexal tenderness, foul-smelling bad discharge


Rectal

WNL


EXT

WNL


Neurological

WNL


Psychiatric

moderate distress


Laboratory and diagnostic testing


Differential

Abnormal Value

Normal Value


Neutrophils: 68% 40-60
Lymphocytes: 13% 20-40
Monocytes: 1800 4-8
Eosinophils: 250 1-3
Basophils: 60 0-1
Bands 7% 0-5


Urinalysis

Color                                      Straw-colored               pale yellow/ amber

specific gravity                       1.015                             1.005, – 1.025

ph                                             8.0                                4.5-8.0

protein                                      negative

glucose                                     negative

ketones                                     negative

Bacteria                                    Many

Leukocytes                               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, KPH prep.WET prep and VDRL negative
 

 

 

Differential diagnoses

1.      Gonococcal cervicitis, unspecified, ICD-10-CM Diagnosis Code A54.03


Plan of care:

N, gonorrhoeae is a fastidious gram-negative intraocular diplococcus. According to treatment guidelines from the (WHO) World Health Organization, treatment should consist of ceftriaxone 250 mg intramuscular (IM) as a single dose PLUS azithromycin 1 g orally as a single dose. (WHO

Neisseria gonorrhoeae

,2016).

Patient education,

according to the CDC fact sheet on gonorrhea, gonorrhoeae essentially transmitted disease that can affect both men and women, it can cause infection in the genitals rectum and throat is a very common infection especially among young people ages 15 to 24. You can reduce the risk of getting gonorrhea, if you are sexually active you can do the following things to you decrease your chance of getting gonorrhea being a long-term relationship (Monogamous). Use latex condoms every time you have sex. (CDC fact sheet,2018)

2. Chlamydial infection of genitourinary tract, unspecified. 10-CM Diagnosis Code A56.2Plan of care. According to the who will help organization guidelines treatment for chlamydia, azithromycin 1 g orally as a single dose doxycycline hundred milligrams b.i.d. or seven days seven days. Patient education, Chlamydia is a common STD that can affect both men and women. You can cause serious permanent damage to a woman’s reproductive system. The only way to avoid STDs as to not have agile and or oral sex be a long-term monogamous relationship with a partner has been tested negative for STD, use latex condoms every time you have sex. Anon, (2019).

STD Facts

3. Personal history of urinary (tract) infections, ICD-10-CM Diagnosis Code Z87.440. plan of care Cipro flaxen 500 mg twice a day for seven days, for treatment of urinary tract infection. According to internal article on the guidelines of treating UTI. According to the CDC fact sheet UTIs are caused by bacteria and are treated with antibiotics. Take antibiotics as the doctor tells you, do not share and about others and do not save them for later. You can help prevent UTIs by doing the following unit after sexual activity, shall instead of baths, minimize douching sprays or powers the genital area (. Kang, C. I 2018)


Reference

  • Kang, C. I., Kim, J., Park, D. W., Kim, B. N., Ha, U. S., Lee, S. J., … Wie, S. H. (2018). Clinical Practice Guidelines for the Antibiotic Treatment of Community-Acquired Urinary Tract Infections.

    Infection & chemotherapy

    ,

    50

    (1), 67–100. doi:10.3947/ic.2018.50.1.67
  • Anon, (2019).

    STD Facts


    – Chlamydia

    . [online] Available at: https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm [Accessed 15 Jan. 2019].
  • CDC (2018).

    Centers for Disease Control and Prevention

    . [online] Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/.
  • ‌WHO guidelines for the treatment of

    Chlamydia trachomatis

    . (2016).

    World Health Organization

    .https://doi.org//entity/reproductivehealth/publications/rtis/chlamydia-treatment-guidelines/en/index.html
  • ‌ WHO guidelines for the treatment of

    Neisseria gonorrhoeae

    . (2016).

    World Health Organization

    . [online] Available at: https://www.who.int/reproductivehealth/publications/rtis/gonorrhoea-treatment-guidelines/en/ [Accessed 9 Oct. 2019].

 

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