The differential diagnosis for this 28 year old female is Pelvic Inflammatory Disease (PID) secondary to the sexually transmitted infections (STIs) of gonorrhea and chlamydia. PID occurs when organisms travel from the cervix to the upper genitourinary tract. Usually, PID is caused by untreated gonorrhea and chlamydia. The symptoms of PID include pain or tenderness in the lower abdomen, or pain in the right upper abdomen. Vaginal discharge that is yellow or green and has an unusual odor is common. Often dysuria is present. Chills, fever, nausea, vomiting and painful sex are often seen with PID
In the case study, a patient presents to the clinic with a chief complaint of dysuria. Females often report dysuria during an acute urinary tract infection (UTI). The client complained of other symptoms consistent with a (UTI) such as urinary frequency and lower abdominal pain. The patient reports that her urine is looking dark. Aside from the symptoms of UTI, the client reports a vaginal discharge. The history of the present illness as stated by the patient includes 1 week of vaginal discharge and 2 days of dysuria. (Torpy, Schwartz, Golub, 2012)
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A review of the systems is done by the provider to ensure that the patient provides necessary data needed for diagnosis and treatment. Additional subjective data reported by the patient includes her past medical history and her family history. The patient reports frequent, recurrent UTI’s. She states that she had 3 in the past year. The patient also reports that she had been diagnosed with gonorrhea twice and had been diagnosed with chlamydia once. Other significant past medical history (PMH) reported by the patient is that she has had 4 pregnancies and 3 births. The patient reports having a tubal ligation two years ago. The patient reports that her last pap smear was done six months ago. She does not take any medications and she denies having any allergies. She does report a sensitivity to Trimethoprim (TOM)/ Sulfamethoxazole which causes her a rash.
Aside from her own past medical history, the patient reveals her family and her social history. The patient is single and lives with a new boyfriend and has three children. She admits to multiple male sex partners. She admits having unprotected sex with her formal boyfriend.
A head to toe assessment is conducted by the provider with the following assessment findings. Neurologically, the patient is within normal limits, no confusion or other neuro deficits. The chest is within normal limits with no asymmetry of adventitious lung sounds noted. The patient’s heart sounds are normal and the rate and rhythm of the heart are within normal limits. Upon palpation, the patient’s abdomen is soft and tender with tenderness increased in the supra pubic area. The patient complains of cervical motion tenderness and adnexal tenderness. A foul smelling vaginal discharge is noted. Rectal exam is normal and the patient’s extremities are within normal limits.
The provider orders laboratory and diagnostic tests for confirmation of the diagnosis and to establish a plan of treatment. Vital signs reflect a temperature of 99.7 degrees Fahrenheit. It is not uncommon to have fever with a pelvic infection. The heart rate is 80, respiratory rate 16 and the patient’s blood pressure is 100/80. All of these vital signs are within normal limits. A white blood cell count (WBC) is done with a differential. An increase in WBC reflects the presence of inflammation and or infection. Neutrophils make up 68% of the WBC count which is normal. Neutrophils typically make up the highest number of WBC, followed by lymphocytes, then monocytes, eosinophils and basophils. The patient has an elevated number of bands, (immature neutrophils). Typically, this number does not exceed 3%. Again, this helps to confirm the diagnosis of gonorrhea with PID. The urinalysis shows an alkaline urine with a PH of 8.0. The urine specific gravity is 1.015. The urine is straw colored which could indicates increased concentration. The urine shows bacteria, leukocytes 10 – 15, and RBC 0-1. The bacteria in the urine indicates a UTI or it could be the result of a contaminated specimen from the vaginal secretions. A urine culture and gram stain is done and gram negative rods are found. Escherichia coli (E.coli), is the major cause of gram – negative rods in the urinary tract. The patient has a positive monoclonal AB for Chlamydia. The VDRL syphilis test for is negative. The KOH Test for Candida Albicans is negative. The wet prep does not confirm a diagnosis of vaginitis. The urine has no ketones or protein.
From the above assessment and diagnostic tests, the patient is found to have three priority diagnoses. The first diagnosis is PID (2012 ICD-9-CM Diagnosis Code 614.9) unspecified inflammatory disease of female pelvic organs and tissues. This diagnosis is supported by the patient’s signs and symptoms of fever, elevated WBC, vaginal discharge, suprapubic and abdominal tenderness, etc. As well, a past history of STI’s and current lab and diagnostic tests such as elevated WBC point to this diagnosis. (CDC, 2015)
The second diagnosis the patient has is UTI (2016/17 ICD-10-CM Diagnosis Code N39.0). The patient exhibited signs and symptoms of UTI including dysuria, fever, abdominal and supra pubic tenderness. As well, the urinalysis shows bacteria and hematuria which indicate UTI. The urine culture shows gram negative rods which are common for E.coli in the urinary tract. (CDC, 2015)
Thirdly, the patient has a diagnosis of Neisseria Gonorrhoeae (2016/17 ICD-10-CM Diagnosis Code A54.9) as evidenced by the vaginal culture. The patient has signs and symptoms of gonorrhea such as abdominal pain, vaginal discharge, dysuria, cervical motion tenderness and fever. (CDC, 2015)
The plan of care for the patient in the case study includes starting IV or oral antibiotic therapy. Broad spectrum coverage of likely pathogens regimens are used to treat PID. This should also be effective against N. gonorrhoeae and C. trachomatis. Doxycycline is often used in the IV or oral form. Sulfa antibiotics are useful against UTIs. Evidence proves that patients who delay antibiotic treatment take longer for the infection to resolve. Analgesics will be given prn for pain and antipyretics will be ordered for prn use. Listed on the prn list of medications as well will be an antiemetic such as Zofran to be taken as needed for nausea. Strict I and O will be kept and fluids will be administered to flush out the urinary tract. Good personal hygiene, including wiping from the front to the back is emphasized. (Torpy, Schwartz, Golub, 2012)
Other teaching points include drinking plenty of fluids (at least three to four glasses of water each day). Emptying the bladder completely as soon as the urge is felt or at least every three hours is emphasized. Plenty of vitamin C is encouraged to make urine acidic and help keep bacteria down. Vitamin C is found in orange juice, citrus fruits, and broccoli. Cotton underwear should be worn because cotton does not trap moisture. Moisture is a haven for bacteria growth. Use a condom during oral, vaginal, and anal sex. Do not have sex with someone who has gonorrhea. Do not have sex while you or your partner are being treated for gonorrhea. Ask when it is safe to have sex. Inform healthcare provider if you are pregnant. Gonorrhea can be passed to an infant during birth. (Torpy, Schwartz, Golub, 2012)
The care plan for the patient in the case study is developed to meet all of the needs of the patient, not just physical needs. Patient care is holistic, focusing on the psychosocial implications of diseases as well. The patient with PID associated with gonorrhea faces psychosocial issues such as isolation, embarrassment, stigma, etc. Relationship status is exposed and sexual self – concept is disrupted. This disease places stress on the family as well as partners. Proper counseling and referrals are essential to the success of treatment for a patient with a STI. These communicable diseases are reportable and strict confidentiality is a must for all healthcare providers. Referrals include pregnancy clinics, family planning, etc. strategies that aim for broad public health benefit
Barriers to effective treatment are education, training and knowledge. Education is costly and training and knowledge have to be sought out by the individual. Often, due to the psychosocial implications, patients do not seek adequate training and knowledge in the prevention and treatment of STIs.
Strategies to overcome these barriers include an increase in federal and state funding to offset the cost of preventative training. Also, the focus should be on training in prevention, not training about the disease once it exists. This will prevent the embarrassment associated with having the disease. People are reluctant to seek training once they actually have the disease because of the stigma that goes along with the disease.
In conclusion, the provider should focus on identification of symptoms, prompt diagnosis, treatment, education and follow up for the patient with PID associated with gonorrhea. The focus is on treating the patient as well as the partners in order to prevent reinfection. This involves a healthcare team interested in treating the patient holistically. Complications from untreated gonorrhea infections are preventable. This is why education is so important. (WHO, 2012)
