Gonococcal Cervicitis and Urinary Tract Infection Plan Care (Case Study Sample)

Gonococcal Cervicitis and Urinary Tract Infection Plan Care
Name
South University Online
Faculty Name
NSG 6001
Date
Gonococcal Cervicitis and Urinary Tract Infection Plan Care


Patient Initials: 28-Year-old female
Subjective Data: 28-year-old female patient visits a clinic and reports that they have been experiencing pain when urinating accompanied by lower abdominal pain whose severity has been increasing in the past week. In addition, she has been experiencing vaginal discharge during that period.
Chief Compliant: Urinary symptoms that look like urinary tract infection for the past two days, lower abdominal pain and a brown vaginal discharge which is smelly, after having unprotected sex with her boyfriend.
History of Present Illness: The current symptoms started two days ago after having unprotected sex with her boyfriend
PMH/Medical/Surgical History: The patient has been treated for urinary tract infections three times in the last 12 months. She has also been treated for gonorrhea twice and chlamydia once. Others are Gravida IV Para III. The only past surgical history is tubal ligation 2 years ago.
Significant Family History: The female patient is currently single and has a history of multiple sexual partners. She has three children and currently lives with her new boyfriend. In addition, she does not smoke, use alcohol, or any drugs.
Review of Symptoms:
General: Weight-120 pounds, Height-5’0, Blood Pressure-100/10, heart rate-80, Temperature 99.7F
HEENT: Within normal limits (WNL)
Cardiovascular: Normal rhythm S1 and S3, regular rate
Respiratory”: Within normal limits
Gastrointestinal: Lower abdominal pain
Musculoskeletal: soft and tender abdomen, increased suprapubic tenderness
Genitourinary: Cervical motion tenderness, adnexal tenderness, foul smell, vaginal drainage
Neurological. Not Applicable
Endocrine: Within normal limits
Hematologic: Within normal limits
Psychologic: Within normal limits
Rectal: Within normal limits
Objective Data:
Vital Signs: BP – 100/80; R -8) T-99.7 F, Wt-120 . ; Ht. 5,0 ; BMI -23.4
Physical Assessment Findings:
HEENT: Within normal limits
Lymph Nodes: Within normal limits
Carotids: Normal rhythm S1 and S3
Lungs: Within normal limits
Heart: Regular rate
Abdomen: lower abdominal pain
Genital/Pelvic: Cervical motion tenderness, adnexal tenderness, foul smell, vaginal drainage
Rectum: Within normal limits
Extremities/Pulses: Regular rate
Neurologic: Not applicable
Laboratory and Diagnostic Test Results: Differential: Neutrophils 68%, Bands 7%, Lymphocytes 13%, Monocytes 8%, Eosinophils- 2% Urine Analysis: Color- Straw colored. Specific gravity 1.015, Urine-Ph 8.0, Urine protein negative, Urine glucose neg, Ketones-negative, Bacteria – many, Leukocyte count 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:
1 Gonococcal cervicitis, unspecified, ICD-10-CM Diagnosis Code A54.03
2 Non-gonococcal urethritis, ICD-10 code N341
3 Urinary tract infection ICD-10 code N39. 0
Plan of Care:
Gonococcal cervicitis is caused by Neisseria gonorrhoeae. World Health Organization treatment guidelines require administration of ceftriaxone