Comprehensive Assessment of a Patient with Chlamydia
Order Instructions:
When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
To prepare: Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.
To complete:
Write comprehensive paper that addresses the following:
•Age, race and ethnicity, and partner status of the patient
•Current health status, including chief concern or complaint of the patient
•Contraception method (if any)
•Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
•Review of systems
•Physical exam
•Labs, tests, and other diagnostics
•Differential diagnoses
•Management plan, including diagnosis, treatment, patient education, and follow-up care
Any one of these topics might be appropriate but must be comprehensive:
- Bacterial vaginosis
- Trichmoniasis
- Chalmydia
- Polycystics Ovarian syndrome
- Yeast infection
- UTI
- Overactive bladder
- Atropic vaginitis
see attachment I sent earlier please
SAMPLE ANSWER
Comprehensive Assessment of a Patient with Chlamydia
Date of Visit: 25/10/2014
DOB: 25/05/1985
Subjective Data
CC: “I feel some Itching around the vagina and bleeding between periods”.
HPI: Mary is 29-year old African-American female who presents herself to the clinic today with complaint of itching around the vagina and bleeding between periods. She reports that she first experienced the itching two to three weeks after having sex with her boyfriend, which has been worsening over time. Related symptoms are pain during menstruation, lose of so much blood in between menstruation and discharge from the birth canal. The patient also complained of having so much pain when urinating but denied having had any diabetes problem. She thought she had bacterial vaginoites and used a lot folate, calcium and vitamin E rich foods none of which have provided any relief. She has also used antibiotic Metronidazole (500 mg twice a day, once every 12 hours) for 7 day which provided some improvement but the problem recurred whenever she had sex.
OB/Gyn History: the patient has used IUD for ten years. A copper IUD for 6 consecutive years then changed to a hormonal IUD until diagnosed with Pelvic inflammatory disease. She received treatment with Doryx, Vibramycin Lupon for abnormal vaginal discharge that is yellow or green in color or that has an unusual odor.
Menstrual history: Before being diagnosed with Pelvic inflammatory disease, at age 19, her cycle lasted 6-8 days with heavy bleeding.
Pregnancy history: During her first pregnancy in 2007, she experienced Pelvic girdle pain, severe hypertensive states and Deep vein thrombosis
History of STIs: History of polycystics ovarian syndrome and urinary tract infection at the age of 23.
Sexual history: She is currently having multiple sex partners with men who are older that her age. In fact, she admits having worked as a prostitute when she was 20 years before deciding to reform. Presently she does not like her lifestyle and she is planning to settle down with one man. Gyn problems/procedures: experiences cramps when using IUD.
Urologic health: Treated for recurrent polycystics ovarian syndrome
Previous Pap test/mammogram: Date of last Pap, 2013 and mammogram in 2014 with normal findings.
Contraceptive use: Uses hormonal IUD as a birth control, however, she is considering the use of condom for barrier protection from sexual transmitted infections (STIs) in order to avoid putting herself at risk always.
PMH: PID and so much bleeding during her periods.
Immunization status: influenza and Tetanus (November 2010)
Medications: Metronidazole (500 mg twice a day, once every 12 hours)
Allergies: allergic to eggs and mosquito bite.
FMH: Mother diagnosed with pelvic inflammatory disease in 1980 died at age 60 in 2012. Father diagnosed with diabetes in 2000 but still alive. Has five siblings, all who are in good health and stay physically active
Psychosocial/Social History/Habits: Patient does farming on her private farm when she plants vegetables.
Review of Systems
Skin: report of skin rash, but no discoloration, no itching and the skin color is very normal
HEENT: Rejects having had any gum disease.
Lymph/neck: does not remember having had any lymph problem,
Thorax/Respiratory: her respiratory system has never had any problem
Breast: there is no nipple discharge, lumps, pain or change in breast size.
GI/Abdomen: experiences vomiting but no nausea vomiting or any changes in bowel habits, Genitourinary: C/o confirms presence of vaginal itching or discharge.
Objective Data
Vital signs: T 96.2 HR 77 RR 22 B/P 144/90 weight 90 Lbs height, 60 inches BMI 24.9
General History: Mary is a 29-year-old well-developed lady with a normal weight. The patient has fever and looks stressed.
General:
HEENT: the head is normocephalic, eyes have no papilledema, ears are noninflammed, throat has no erythena, and mouth has no thrush while the neck is supple.
Lymph Nodes: they are not infected
Thyroid: absence of hyperthyroidism.
CVS: RRR, SI and S2, no murmurs, gallops, heaves, thrills, rubs, carotid artery bruit
Thorax/ lungs: the lungs have no infection
Breast exam: the breasts have no masses, lumps, rashes lesions.
Gastrointestinal: Abdomen flat, non-distended with active bowel sounds in all quadrants, no hepato-splenomegaly. There is no tenderness with deep palpation.
Pelvic Examination:
External Genitalia: Bartholin’s and skenes glad normal, mons pubis with scanty hair, labia appears dry and majora extends partially to the perineum, vaginal wall pale smooth and shiny. Erythemaous with increased friability, vaginal discharge sticky, brownish, and vaginal mucosa appears thick and pale loss of rugal folds and elasticity.
Adnexae: bilaterally tender without mass.
Musculoskeletal noncontributory
Neurologic: non-contributory
Assessment
A: Primary Diagnosis:
A: Diagnosis:
Chlamydia infection is the most common sexually transmitted infection in both men and women (Alexander, 2010). Sexually active individuals and individuals with multiple partners are at highest risk. The common symptoms include, abnormal vaginal discharge that may have an odor, bleeding between periods, Painful periods, abdominal pain with fever, Pain when having sex, Itching or burning in or around the vagina and Pain when urinating (Yancey, 2012).
Diagnostic lab test /culture
Chlamydia is tested depending on the microorganism found by cell culture method in the lab. Non cultures are very specific and are used to test a population with more than 10% infection with Chlamydia.
Respiratory chlamydioses is tested using assay for changes in antibody titer .
Differential Diagnoses
UTI: is a disease of the urinary tract whose symptoms include a burning feeling when the person is urinating and pain in the back pain. This condition was ruled out because with this condition the patient always feels the urge to urinate even though little comes out (Yancey, 2012).
Bacterial vaginosis: the patient has vaginal discharge. The disease was done away with because BV is not so serious and women do not visit the doctor. About 1 in 3 women may have BV in their lives (Yancey, 2012).
Plan
Antibiotic treatment regimens for uncomplicated genital chlamydial infection are: azithromycin (1 g orally as a single dose) or doxycycline (100 mg twice daily for 7 days). Uncomplicated infection should be treated with azithromycin 1 g as a single oral dose. Those people with erratic health-care-seeking behavior, poor treatment compliance or unpredictable follow-up, azithromycin might be more cost-effective. Erythromycin, levofloxacin and ofloxacin are effective alternatives to azithromycin and doxycycline (Chernecky & Berger 2013).
Medications: use of antibiotics, including tetracyclines, azithromycin, or erythromycin. Those infected should get treated to prevent transmitting the disease. If a person contracts Chlamydia, the person is not protected from contracting the disease again. Those women who suffer from PID should use antibiotics for a very long time or stay in the hospital for intravenous antibiotics. Some severe pelvic infections may require surgery in addition to antibiotic therapy (Fischbach & Dunning, 2009).
Education
Those who engage in sex should get tested every year. Because of the chance of other health problems if you contract Chlamydia, ask your caretaker on the number of times to go for check up (Breguet, 2006). The female are encouraged to do the test since the problem is so rampant in them.
Follow-up: A follow-up evaluation may be done in 4 weeks to determine if the infection has been cured (Alexander, 2010).
Conclusion
Without any doubt, I was so convinced in the medical plan given to this patient. However, I realized that most young gals are ignorant on the relevance of going for medical checkups for Chlamydia. This has made these ladies to be unwilling to visit the medical providers. The reason for the unwillingness is that, they are not ready to share their personal life with anyone else. This condition is more challenging and does not respond to one treatment, thus, control is based on the nature of the disease and the severity. Sometimes, so many treatments have to be tested before settling on the best form. Different forms of treatment have to be used in order to realize good results and also there should be National testing of every person that is above 18 years in order to stop the spread of the disease at a very early stage. The patient was educated about the medications of the disease and advised to visit a doctor.
References
Chernecky, C. C., & Berger, B. J. (2013). Laboratory tests and diagnostic procedures. St. Louis, Mo: Elsevier/Saunders.
Fischbach, F. T., & Dunning, M. B. (2009). A manual of laboratory and diagnostic tests. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Yancey, D. (2012). STDs.
Breguet, A. (2006). Chlamydia. New York: Rosen Pub. Group.
Goldman, M. B., Troisi, R., & Rexrode, K. M. (2013). Women and health. Amsterdam: Elsevier Science.
Alexander, L. L. (2010). New dimensions in women’s health. Sudbury, Mass: Jones and Bartlett Publishers.
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