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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
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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.
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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.
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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
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