Comprehensive History and Physical Examination

Table of Contents

Identifying Data: 28 years old female

Reasons for Seeking Health Care: Urinary symptoms; burning and pain upon passing urine, brown foul smelling vaginal discharge after sexual intercourse with a boyfriend, and lower abdominal pain.

History of Present Illness: The patient came to the clinic with complain of recurrent abdominal pain and brown foul smelling vaginal discharge for the last two days. There is neither an existing reliever nor treatment used by the client.

Medication: None

Allergies: None

Past Medical History: The client noted that she has had three recurring UTIs, Chlamydia X1, gonorrhea X2, and Gravida IV Para III. The patient also had trimethoprim rash.

Past Surgical History: The client underwent tubal ligation two years ago.

Family History: The patient is a single parent. She has a history of multiple male sexual partners. She currently lives with new boyfriend and 3 children.

Social history: The patient denies smoking, alcohol and drug use.

Review of Systems: Most of her systems are properly functional. The physical assessment does not give clear data on what could cause the brown foul smelling vagina discharge or lower abdominal pain. Trimethoprim (TOM), ROS last pap 6 months ago. The patient denied experiencing any breast discharges and her urine looked dark.

Complete Physical Examination

  • Vital Signs: Pulse 85, temperature 99.7 f, blood pressure 100/80, weight 120, height 5’0, respiration 16, and HR 80.
  • Respiratory: Normal movement with effortless and metrical respirations through the nose at about 15-17 inhalations and exhalations per minute. The Supraclavicular lymph nodes are okay.
  • Cardiovascular and Peripheral Vascular: The pulse rate is normal S1 and S2 with no pulsation within aortic areas or sign of varicose. The pressure measurement indicates that patient is predisposed to high blood pressure.
  • Abdomen: The abdomen has asymmetrical appendectomy scar with abnormal contours that have blemished color. The peristalsis has visible movements with audible auscultation bruits. No bowel sound recorded. The abdomen is soft, tender, and increased suprapubic tenderness.
  • GU: Cervical motion tenderness, adnexal tenderness, bad smelling vaginal drainage.
  • Chest: WNL.
  • Rectal: WNL.
  • EXT: WNL.
  • NEURO: WNL.
  • Testing Results
  • Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
  • UA: Straw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 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, KOH preparation, Wet preparation, and VDRL negative.

Assessment

Differential Diagnoses: Tests were carried out for three possible conditions as revealed by the symptoms. The tests were carried to confirm Chlamydia/gonorrhea infection, trichomonas, and epididymitis, considering that the medical history suggest that client has been treated before of similar conditions. During the microscopic exam, the absence of diplococcus could suggest possible Chlamydia (Workowski & Bolan, 2015). The positive results for the antibody test with regards to HSV-2 suggest possible HSV infection. The urinary culture is positive, which suggest a possibility of epididymitis. The urine culture was positive for mid-stream test to suggest possible presence of a causative infectious agent (Bai, Bao, & Cheng, 2012).

Final diagnosis: The final diagnosis through use of repeated differentiating test indicated Chlamydia/gonorrhea infection since diplococcus was absent with sufficient WBC. This was confirmed by the NAAT to define the pathogenic diagnosis (Athena Health Services, 2017).

Plan

Medication: Dual therapy with two antimicorbials to cover gonorrhea and Chlamydia. Oral cefixime will also be given alongside a single dose of cephalosporins. The drugs will be administered over a period of between 10 and 14 days (Hay, Levin, Deterding, & Abzug, 2014).

Additional diagnosis tests: Additional tests were performed to confirm if the infection was complicated or not. The results indicated that the infection is uncomplicated gonococcal (Lozoff, Castillo, Clark, & Smith, 2013).

Education: The patient was advised on the need to convince her sexual partner to undergo similar test and possible treatment to avoid reoccurrence of the infection. The patient was also advised to user safer sexual methods such as condoms (Schuiling & Likis, 2013).

Pediatric notes: Since the patient did not have any history of allergy to drugs, a dose of cephalosporins injection was administered followed by a prescription consisting of oral cefixime and antimicobials.

Referrals: The referrals were made to past history of gonorrhea and Chlamydia infection.

Follow up: Done every three days for 14 days.

Reflection: The patient responded well to treatment and the symptoms cleared after 10 days. The patient was advised to visit the clinic for further tests after three months. During the period of treatment, the patient was able to come with her male sexual partner who was also tested and subjected to similar treatment.

Interdisciplinary Team: The team was made up of nurse practitioner, doctor, social worker. The doctor reviewed the condition of the patient and recommended the treatment method. The nurse practitioner carried out assessment of the patient from time to time. The social worker provided emotional support to the patient and counseling.

Facilitators and Barriers: The proactive teamwork and treatment coordination among the medical personnel ensured effective and timely diagnosis and treatment. However, it took a lot of convincing for the patient to bring along her sexual partner. This challenge was addressed by sending the social worker who managed to counsel and convince him to enroll in the treatment plan.

Conclusion: From the comprehensive plan and care, it was apparent that the symptoms, medical history, social history, and teamwork facilitated accurate diagnosis and treatment of the patient who was suffering from Chlamydia/gonorrhea infection.

References

Athena Health Services. (2017). Gonorrhea infection. Web.

Bai Z., Bao, J., & Cheng, W. (2012). Efficacy and safety of ceftriaxone for uncomplicated gonorrhoea: a meta-analysis of randomized controlled trials. Interational Journal STD AIDS, 23(4), 126-132.

Hay, W., Levin, M., Deterding, R., & Abzug, M. (2014). Current diagnosis and treatment: pediatrics. Web.

Lozoff, B., Castillo, M., Clark, K., & Smith, K. (2013). Iron-fortified vs low-iron infant formula: developmental outcome at 10 years. Archives of Pediatric and Adolescent Medicine, 166(3) 208-215.

Schuiling, K., & Likis, F. (2013).Women’s gynecologic health. Web.

Workowski, K., & Bolan, A. (2015). . Web.

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