Genitourinary Case Study and Care Plan

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22nd May 2020 Nursing Case Study Reference this

Tags: medicalgenitourinary

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Genitourinary Case Study

Patient Initials __28-year-old Female

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 & chemotherapy50(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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