Posted: September 17th, 2022

Focusedsoap notice on gynecologic well being: Case Research 1, week three, NRNP 6552.

Affected person Info:

C. B, 22 years outdated, Feminine, Caucasian.

S.

CC (chief criticism): The affected person complained of a burning sensation throughout urination and vaginal discharge for one week

HPI: C. B., 22 years- outdated feminine affected person, introduced with a criticism of a burning sensation ring urination and has been having yellow watery vaginal discharges for every week. Affected person-reported her boyfriend just lately examined optimistic for chlamydia, and she or he is apprehensive. The affected person additionally reported having just one sexual accomplice and has not had sexual contact with anybody else.

Present Medicines: The affected person experiences she takes Srintec oral contraceptives day by day and multivitamins.

Allergic reactions: No recognized drug allergy symptoms, no recognized meals allergy symptoms.

PMHx: The affected person document reveals she is totally vaccinated and has just lately gotten her flu shot for this yr, and is updated with the covid vaccine. The affected person has a previous medical historical past of melancholy and nervousness however just isn’t on drugs.

Soc & Substance Hx: the affected person experiences she is a social drinker, has by no means smoked, and has by no means used leisure medication. The affected person lives at house together with her mother and siblings and works.

Fam Hx: mom is alive with breast most cancers in remission and hypothyroidism. Her paternal grandfather is alive with prostate most cancers. Her sister has kind 1 diabetes as properly. Her father has HTN, diabetes kind 2, and hyperlipidemia.

Surgical Hx: No prior surgical historical past reported.

Psychological Hx: Prognosis of Nervousness and melancholy. No historical past of self-harm practices and/or suicidal or homicidal ideation ever.

Reproductive Hx: affected person reported she prefers male companions. She reported she has just one sexual accomplice, and she or he is sexually energetic. The affected person experiences she has by no means been pregnant, LMP is 08-23-2022.

ROS:

GENERAL: affected person reported no latest weight reduction, fever/chills, weak point, or fatigue.

HEENT: Eyes: No visible loss or double imaginative and prescient. Ears, Nostril, Throat: No listening to loss, sneezing, congestion, runny nostril, or sore throat.

SKIN: pores and skin is dry with no rash or itching.

CARDIOVASCULAR: No chest ache or chest discomfort. No palpitations.

RESPIRATORY: No shortness of breath and no cough.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea.

NEUROLOGICAL: No headache, dizziness, syncope, or paralysis. No change in bowel or bladder management.

MUSCULOSKELETAL: No muscle ache, joint ache, or stiffness. Energetic in all extremities.

HEMATOLOGIC: No bleeding or bruising.

LYMPHATICS: No enlarged nodes or historical past of splenectomy.

PSYCHIATRIC: optimistic historical past of melancholy or nervousness.

ENDOCRINOLOGIC: No experiences of sweating or chilly or warmth intolerance. Delicate sweating within the palms because of nervousness.

GENITOURINARY/REPRODUCTIVE: Burning on urination. LMP: 08/23/2022. Watery yellow discharges in giant quantities.

ALLERGIES: No recognized allergy symptoms.

O.

Bodily examination: Normal: V/S embrace; Top-5’ 5”, Weight -148 (BMI 24.6), BP-132/68, P-62, R-22, T-98.6, O2- 98% RA. Affected person in no bodily misery, alert, and oriented to particular person, place, time, and scenario.

Head/ Neck: Normocephalic and atraumatic. Lymph nodes are grossly regular.

EENT: Denies imaginative and prescient loss, listening to loss, nasal congestion and/or discharges, and sore throat.

Lungs/CV: Chest is obvious to auscultation bilaterally, regular respiration, rhythm, and depth upon examination. Denies palpitations and chest ache.

GI: Denies nausea, vomiting, diarrhea, and anorexia.

Musculoskeletal: Energetic in all extremities with a gradual gait.

GU: Affected person is optimistic for burning sensation when urinating and denies frequent urination. Constructive for yellow watery vaginal discharges with a powerful odor. Constructive for decrease belly ache on palpation, cervix agency and easy. The uterus is cell and non-tender. The breast examination is regular on palpation, and no nodules have been famous.

Psych: Affected person is reasonably anxious, has delicate sweating, and respirations of 22. Capable of comprehend and narrate historical past.

Diagnostic outcomes: Embody nucleic acid amplification exams (NAATs), which embrace vaginal swabs assortment, urine Assessment, and tradition. Check outcomes have been optimistic for Chlamydia, it was detected within the swab and the urine samples.

A.

Major and Differential Diagnoses; Major is Chlamydia

Cervicitis: irritation of the cervix normally attributable to an infection, publicity to chemical publicity, or the presence of a overseas physique. Signs embrace; uncommon vaginal discharges, painful intercourse, painful urination, irregular vaginal bleeding, and strain within the pelvis.

Pelvic Inflammatory Illness: an an infection of the feminine reproductive organs as a result of unfold of sexually transmissible micro organism from the vagina to the uterus, fallopian tubes and ovaries. Signs embrace pelvic ache, fever, vaginal discharges, painful menstruation, nausea/vomiting, and decrease stomach/again ache.

Gonorrhea: A venereal illness involving inflammatory discharge from the urethra and vagina, it’s attributable to a sexually transmissible micro organism, and signs embrace; ache within the decrease stomach/again, painful urination, and vaginal discharges.

P.

Therapy contains;

Doxycycline 100 mg PO twice day by day for seven days.

Azithromycin 1g as soon as by mouth – day 1, adopted by 500mg as soon as day by day for two days.

Ibuprofen 600 mg PO as wanted.

Chlamydia is an STI that may trigger everlasting injury to a lady’s reproductive system if not correctly handled, inflicting the impossibility of getting pregnant at a later age. Chlamydia could cause probably deadly ectopic being pregnant.

Conclusively, I agree with the therapy routine above, as it’s the first-line therapy advisable by CDC for this an infection, Davidson et al., 2021.

A sexually transmitted illness case report was accomplished and returned to the Division of Well being publish analysis of chlamydia as advisable by the state.

Affected person training is given to the affected person on screening for HPV and different STIs and prevention. The affected person was additionally educated on the illness chlamydia and its long-term results, and the way it may be prevented.

Observe-up scheduled in a single month with the Gynecologist. If there’s any response to the prescribed drugs, the affected person ought to attain out to the clinic as quickly as potential. The affected person was knowledgeable concerning the therapy of her accomplice if has not began therapy but.

Extra questions requested to the affected person embrace:

Are you able to inform in case your boyfriend has one other accomplice?
Do you follow oral and anal intercourse?
Are you able to clarify how this complete scenario impacts your on a regular basis actions
What do perceive by venereal illnesses or sexually transmitted illnesses?
References

Davidson, Ok. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., … & US Preventive Providers Process Power. (2021). Screening for Chlamydia and Gonorrhea: US preventive companies job power advice assertion. JAMA, 326(10), 949-956.

Frej-Mądrzak, M., Gryboś, A., Gryboś, M., Teryks-Wołyniec, D., Jama-Kmiecik, A., Sarowska, J., & Choroszy-Król, I. (2018). PCR diagnostics of Chlamydia trachomatis in asymptomatic an infection by ladies. Ginekologia Polska, 89(three), 115-119.

Hammerschlag, M. R., & Sharma, R. (2021). Azithromycin within the therapy of rectogenital Chlamydia trachomatis infections: finish of an period?. Professional Assessment of Anti-infective Remedy, 19(four), 487-493.

Huai, P., Li, F., Chu, T., Liu, D., Liu, J., & Zhang, F. (2020). Prevalence of genital Chlamydia trachomatis an infection within the basic inhabitants: a meta-analysis. BMC infectious illnesses, 20(1), 1-Eight.

Kong, F. Y. S., Tabrizi, S. N., Legislation, M., Vodstrcil, L. A., Chen, M., Fairley, C. Ok., … & Hocking, J. S. (2014). Azithromycin versus doxycycline for the therapy of genital chlamydia an infection: a meta-analysis of randomized managed trials. Medical Infectious Illnesses, 59(2), 193-205.

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