Question

James Lewis is a 24-year-old male who is seen in the clinic for "pain in the groin." During the interview the patient states, "I have a soreness in my groin area on both sides." Mr. Lewis denies any trauma to the area, states he has not done any heavy lifting, nor has he been involved in athletic activities or "working out." He reports that he is in good health. He does not take any medications except vitamins and, occasionally, some non-aspirin product for a headache. He denies nausea, vomiting, diarrhea, or fever. He has no pain in his legs or back. He tells the nurse his appetite is okay but he is tired. He thinks his fatigue is because he's been "a little worried about this problem and really having a hard time deciding to come in for help."

When asked about the onset of the problem, Mr. Lewis explains that he "started feeling some achiness about a week ago." When asked if he has ever experienced these feelings before, he replies, "No." He is then asked to describe or discuss any other symptoms. He looks away, shifts in his chair, and then says, "Well, I have had some burning when I pass urine and it's kind of cloudy."

When asked if he has ever had a problem like this before, he replies, "Yes, about 2 months ago." With further questioning, the nurse learns that Mr. Lewis was diagnosed with gonorrhea and treated with an injection and pills he was supposed to take for a week. He says he was not supposed to have sex until he finished the pills. When asked if he followed the prescribed treatment, he reluctantly responds that he finished all but a couple of pills and he did have sex with one of his girlfriends about 4 or 5 days after he got the injection. Mr. Lewis tells the nurse he did not inform his girlfriends of his problem and he generally avoids condoms because "I've known these girls for a long time."

The physical assessment yields the following information: B/P 128/86, P 96, RR 20, T 98.6. His color is pale, and the skin is moist and warm. External genitalia are intact, without lesions or erythema. There is lymphadenopathy in bilateral groin areas. Compression of the glans yields milky discharge. A smear of urethral discharge is obtained.

The nurse knows that Mr. Lewis's original gonococcal infection was treated with an injection, most likely ceftriaxone. The nurse also knows that chlamydia is present in almost half of the patients with gonorrhea and is treated with a 7-day regimen of oral antibiotics. Between 40% and 60% of patients with gonorrhea have lymphadenopathy.

Based on the data, the nurse suspects that Mr. Lewis has a reinfection with gonorrhea and may have a concomitant chlamydial infection.

The nurse recommends single-injection treatment for gonorrhea and a new oral regimen for chlamydia. A urine specimen will be obtained and submitted with the urethral discharge smear. The patient will be scheduled for a follow-up phone conference about the laboratory results in 48 hours and a return visit in 7 days. The nurse conducts an information, education, and advice session prior to discharge from the clinic

Jessica Johnson, a 24-year-old Caucasian female, arrives in the clinic with lower abdominal pain and nausea. She states, "I've had this throbbing pain for 3 days and it kept getting worse." She further states, "I haven't been able to eat. I feel awful. You have to do something for the pain."

The nurse explains that more information is needed so that the proper treatment can be initiated. In further interview the following information is obtained. Ms. Johnson's last menstrual period was 1 week ago and she had more crampiness than usual. She has had brownish, thick vaginal discharge on and off since then. She has had some itchiness in the vaginal area and burning when she voids. She states she has to go to the bathroom all the time: "All I did was pee little bits, until this pain got to me. I have hardly gone since last night."

When asked about the pain, Ms. Johnson says it is mostly 8 on a scale of 1 to 10 and getting pretty constant. "Nothing I do helps, except it helps a little if I curl up and hold still."

Physical assessment reveals a thin, pale female. VS: B/P 108/64, P 92, RR 20, T 101.4°F. Skin is hot, dry, poor turgor. Mucous membranes dry. Posture—abdominal guarding. Abdomen BS positive in all 4 quadrants , tenderness in RLQ  drainage, pain upon cervical and uterine movement. Cultures from vaginal secretions obtained To lab, Blood drawn for CBC, To lab Urine specimen obtained—clear, yellow To lab

The patient's clinic record reveals that she has been sexually active since age 16. She has had multiple partners and one abortion. She has been treated for an STD three times, most recently 2 months prior to this visit. The patient is on birth control pills. She has no allergies to medications, and no family history of cardiovascular, abdominal, neurologic, urologic, endocrine, or reproductive disease.

Interpretation of the data suggests a diagnosis of PID. The options are outpatient treatment with antibiotics and education about limitations in activity and sexual practices, or inpatient treatment with intravenous fluids, antibiotics, analgesia, and bed rest.

Because Ms. Johnson is acutely ill, with pain and dehydration, she is admitted to the acute care facility with a diagnosis of PID.

questions:

Clinical Challenge question:

1.What healthy people 2020 objectives are related to each scenario: James Lewis and Jessica Johnson?

Answer 1

Chlamydia and gonnorhea are the most common problems occurs in sexually active people with more than one partner.By reinforcing the importance of continuing medication and by educating the patient about the infection and lifestyle changes can reduce the risk of infection.The spread of STDs contributes several factors like age, gender, racial and ethnic groups. By promoting patient home and community based care about the infections and reinforcing the need for annual screening for chlamydia and other STDs is an important part of patient education. Because these infections have serious effect on future health. Exploring options with patients ,determining their safer use of safer sex practices and their knowledge deficits and correcting misinformation may prevent mortality and morbidity.The patient must be informed of the need for precautions and must be encouraged to take part in procedures to prevent infecting others and protecting themselves from reinfection.