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1 Genitourinary Clinical Case Study Student’s Name Institutional Affiliation GENITOURINARY CLINICAL CASE STUDY Introduction. Women are prone to infection of the urinary tract more so than their male counterparts due to anatomical differences. The lifetime risk for UTI in women is fifty percent, therefore clinicians are urged differentiate, diagnosis, and treat those women presenting with signs and symptoms that appear as cystitis but can, in fact, be signs of new or recurrent gonorrhea or chlamydia or the progression of pelvic inflammatory disease (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013, p. 733). Subjective Data. Patient is a 28-year-old female, who presents to the clinic today in moderate distress, status post tubal ligation two years ago. The patient’s chief complaint is “a two-day history of frequency, burning, and pain upon urination”, additionally she has had “increased lower abdominal pain and vaginal discharge over the past week”. She is experiencing severe lower abdominal pain accompanied by foul smelling discharge which began after having unprotected intercourse with her former boyfriend. Past medical history includes a tubal ligation two years ago. HM has been pregnant on four occasions and has three children. One pregnancy, however, failed to carry to term. She has had recurrent UTIs (three this current year). HM has had a history of gonorrhea X2, chlamydia X1. She is single but has a history of multiple sexual partners. She denies the use of recreational drugs, smoking, or alcohol use. Review of Symptoms. Review of symptoms is as follows: HM had a Pap smear six months ago. General: 28-year-old, female in moderate distress; Head: Denies, WNL; Eyes: Denies, WNL; ENT: Denies, WNL; Cardiovascular: Regular rate and rhythm, normal S1 and S2; Chest: Denies breast discharge, WNL. Respiratory: Denies, clear to auscultation in all fields; Gastrointestinal: Abdomen is soft, tender, with increased suprapubic tenderness; Genitourinary: Positive for dark urine, cervical motion tenderness, adnexal tenderness, brown 2 3 GENITOURINARY CLINICAL CASE STUDY foul-smelling vaginal discharge, urinary urgency accompanied by pain upon urination and increased pain X 1 week; Rectal: WNL. Objective Data. Vital Signs: BP – 100/80; HR - 80; RR – 16; T – 99.7; Wt. – 120; Ht. – 5’0. These factors compute body mass index (BMI) to 23.4. A BMI of 18.5 – 24.9 Physical Assessment Findings Physical Findings Assessment General: 28-year-old, female in moderate distress, borderline febrile at 99.7° HEENT: Within normal limits. Lymph Nodes: Within normal limits. Carotids: Regular rate and rhythm, normal S1 and S2. Lungs: Within normal limits. Heart: HR - 80, S1S2: regular rate and rhythm. Abdomen: The abdomen is soft, tender, with increased suprapubic tenderness. Positive for dark urine, cervical motion tenderness, adnexal tenderness, brown foul-smelling vaginal discharge, urinary urgency accompanied by Genital/Pelvic: pain upon urination and increased pain X 1 week. Rectum: Within normal limits. Extremities/Pulses Within normal limits. Neurologic: Within normal limits. Assessment and Priority Diagnoses with ICD-10 Codes. GENITOURINARY CLINICAL CASE STUDY 1. A54.9 Gonococcal infection unspecified as evidenced by vaginal discharge culture positive for gram-negative diplococci, Neisseria gonorrhoeae accompanied by brown foul-smelling vaginal discharge. 2. A56.09 Chlamydial infection of lower genitourinary tract, unspecified as evidenced by a positive result for monoclonal AB for chlamydia. 3. Pelvic inflammatory disease (PID) as evidenced by a borderline temperature of 99.7 and positive for dark urine, cervical motion tenderness, adnexal tenderness (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013, p. 812-813). Plan of Care. According to the CDC (2015), the best course of therapy for gonorrhea is dual therapy such as Ceftriaxone 250mg IM and Azithromycin 1 gram orally (CDC2, 2015). Patients must be advised to adhere to the medication to cure the current disease process and medications should not be shared with partners with potential infection In addition to the gonorrhea medication recommendations, the CDC recommends that chlamydial infections be treated with the previously mentioned Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice a day for 7 days (CDC 1, 2015). Evaluation of Priority Diagnosis. HM has two primary diagnoses: Gonococcal infection unspecified and chlamydial infection of lower genitourinary tract, unspecified. HM has two STIs that have been transmitted to her from sexual intercourse. HM progressed from asymptomatic to symptomatic of various disease processes over the course of two weeks.. She may also have future recurrent spontaneous abortions. PID can also cause abscesses requiring surgical intervention which could affect the dynamics of an already unstable family. 4 GENITOURINARY CLINICAL CASE STUDY Facilitators and Barriers.. Barriers to HMs disorder management include lack of health insurance, poverty, and education level (CDC4, 2015). As previously mentioned, providing HM with the CDC pamphlets and including a social worker to assist in seeking resources available specifically for people with situations like HM. Conclusion. As nurse practitioners, we must always educate our patients; preventative strategies are first and foremost when treating patients. It is not enough to administer medications, education, and treating holistically is the framework of nursing practice. 5 GENITOURINARY CLINICAL CASE STUDY References Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative approach (4th ed.). St. Louis, MO: Elsevier. Centers for Disease Control and Prevention (CDC 1). (2015). Chlamydial Infections - 2015 STD Treatment Guidelines. Retrieved from https://www.cdc.gov/std/tg2015/chlamydia.htm Centers for Disease Control and Prevention (CDC 2). (2015). Gonococcal Infections - 2015 STD Treatment Guidelines. Retrieved from https://www.cdc.gov/std/tg2015/gonorrhea.htm Fischbach, F., & Dunning, M. B. (2015). A manual of laboratory and diagnostic tests. 9th Edition. Philadelphia, PA: Wolters Kluwer Health. National Heart, Lung, and Blood Institute. (2015). Calculate Your BMI - Standard BMI Calculator. Retrieved from https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm 6
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Running Head: GENITOURINARY CLINICAL CASE STUDY

Genitourinary Clinical Case Study
Student’s Name
Institutional Affiliation
Date

1

GENITOURINARY CLINICAL CASE STUDY
Introduction. Females are susceptible to to septicity of the urinary strip or track most of the
time compare to their men colleagues as a result of anatomical variances. The generation threat
of UTI in females is 50%, hence health officers are encouraged to distinguish, analysis, and
treatment those ladies having symptoms and indications that seem to be cystitis but will, in fact,
be signs of new or recurrent gonorrhea or chlamydia or the progression of pelvic inflammatory
disease (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013, p. 733).
Subjective Data. Patient is lady aged 28, who presents to the clinic today in moderate distress,
status post tubal ligation two years ago. The sick’s main grievance is “history of a 2 days’
occurrence, scorching, and ache on urinating”, furthermore she must have been in possession of
“high lower abdominal aching and discharge from the vagina on the previous days”. She is
undergoing intolerable abdominal pain followed by smelly release which usually begins when
one has just had exposed sexual intercourse with her ex-b...


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