Chlamydia: Case Study Decision Tree



Chlamydia: Case Study Decision Tree

Nursing 706 Otterbein College

Lisa J. King

Chlamydia: Case Study and Decision Tree

By Lisa King, RN, BSN

Chlamydia is the most commonly diagnosed sexually transmitted infection worldwide with an increased prevalence in women between the ages of 15 and 24 years old. It is transmitted by unprotected vaginal, anal and oral sex. Chlamydia is found to contribute to several reproductive complications such as pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy and infertility. Using a case study format this article will examine differential diagnoses and treatments for Chlamydia.

Chief Complaint: “I have been bleeding between my periods for the past two months.”

History of Present Illness: Barbara is a married, white 22 year old female. She started her menses at age 9 and reports having problems with bloating, cramping, irritability and emotional changes during her periods. She states her periods are 4-5 days in length with a moderate amount of bleeding and have been regular since she started the birth control pill at age 18. Barbara states that for the past two months she has experienced bleeding between her periods. She denies pain or bleeding with intercourse. She complains of a moderate amount of yellowish colored discharge without odor. Barbara states that she has mild lower abdominal pain at times and slight burning with urination, but denies urinary urgency or frequency. She denies vaginal itching or fever. Barbara states that these symptoms are not any worse or better in relation to her regular menstrual cycle and states that she has not tried any measures to relieve these symptoms.

Current Medications:

Levora birth control pills once daily

Over the counter multivitamin daily

Tylenol as needed for abdominal cramping

Past Medical History: Barbara has a past medical history of ovarian cysts in 2004. She states she was started on birth control pills and has since had no problems. Barbara also has a history of kidney stones in 2006 and a Chlamydia infection in August of 2007. In 2007 Barbara also had an abnormal PAP exam showing LSIL which was followed by a colposcopy procedure. No further medical intervention was needed for this incident. Allergies: PCN – rash; Zithromax – rash

Past Surgical History: Colposcopy procedure 6/29/07. No other surgical procedures noted.

Family History:

Mother 43 years old with type II diabetes, has regular periods

Father 45 years old alive and well with history of HTN

Maternal grandmother with a history of hyperlipidemia

Maternal grandfather with a history of HTN, hyperlipidemia and stroke

Paternal grandmother alive and well

Paternal grandfather died at age 64 of an MI

Social History: Barbara is a 22 year old married mother of one. She had a two year old son via an uncomplicated vaginal delivery in May of 2006. She and her husband plan on trying to have another child in the next year. She has had two total sexual partners in her lifetime, one in the past year. Barbara admits to drinking socially, once every two weeks and denies the use of tobacco or other illegal drugs. Barbara works at an insurance company part time and enjoys spending her extra time with her son.

Decision Point 1: Focused History, Physical Examination, Laboratory Tests

History: The history is focused at identifying the cause of Barbara’s breakthrough bleeding. The following questions are to determine the cause of her irregular bleeding patterns.

➢ When was your last regular menstrual cycle?

➢ Is there a chance you could be pregnant?

➢ Do you have any bleeding or pain after intercourse?

➢ Do you notice a foul vaginal odor?

➢ Do you have any abdominal pain?

➢ Are you taking any other herbs or medications?

➢ Describe your relationship with your husband. Do you get along well? Any areas of conflict or abuse?

➢ Have you ever been sexually abused?

➢ Are you experiencing any excessive discharge or itching?

➢ Do you notice any burning with urination?

➢ Have you had any nausea or vomiting?

➢ Have you had a fever?

➢ Have you ever had an abnormal Pap smear?

➢ Have you ever had a CT scan of the abdomen or an abdominal ultrasound?

Physical Exam Findings-

Vital Signs:

➢ Blood Pressure: 120/74 mm Hg in the right arm, sitting

➢ Hear rate: 84 beats per minute

➢ Respiratory rate: 18 breaths per minute

➢ Temperature: 98.8 degrees F

➢ Height: 5 feet, 1 inch; weight: 157 pounds; body mass index (BMI): 30 kg/m

General: Barbara is a pleasant, well groomed 22 year old female. She is in no apparent

distress. She asks questions appropriately and makes direct eye contact with the nurse

practitioner student. She has a steady gait with no physical deformities. She is able to

ambulate without assistance. Her speech is clear and hearing is normal.

Skin: Skin color pink. Skin warm and dry. Nails without clubbing or cyanosis. No rash, petechiae, or ecchymoses.

Head and Face: The skull is normocephalic/atraumatic. Medium reddish brown hair is evenly distributed, with average texture. No alopecia or balding spots noted. Facial expression appears happy, symmetrical.

Eye: External eyes appear symmetrical in shape and position. Peripheral vision intact. Extraocular muscle movement conjugate, without nystagmus or lid lag. Sclera white, conjuctiva pink. Pupils are 3 mm constricting to 2 mm, equally round and reactive to light and accommodations.

Ear: Acuity good to whispered voice.

Nose: External appearance symmetrical with no deformities. No sinus tenderness.

Mouth and throat: Lips pink and moist without cracking or ulcerations. Buccal mucosa without incidence. Tongue pink, symmetrical with no ulceration. No white or erythemic areas noted under tongue or on floor of the mouth. Hard and soft palate intact. Anterior and posterior pillars, uvula, tonsils and pharynx pink without exudates, swelling or ulcerations. Uvula vibrates but remains midline upon patient speaking Ahh. Oral mucosa pink, dentition.

Neck: Neck symmetrical with no masses or scars. Trachea midline. Neck supple; thyroid palpable without notches or masses. No palpable cervical, preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, supraclavicular lymph nodes. Carotid pulses palpated, no bruit auscultated. Range of motion and muscle strength against resistance without incident.

Chest, Posterior: No areas of tenderness or abnormalities noted on posterior chest. Thorax is symmetric with symmetrical expansion. Breath sounds vesicular; no rales, wheezes, or rhonchi. No adventitious lung sounds audible.

Chest, Anterior: Anterior thorax symmetric with good expansion. Lungs resonant. Breath sounds equal and clear bilaterally with no rales, wheezes or rhonchi.

Upper Extremities: Patient able to perform active range of motion of hands, arms, elbows, and shoulders without difficulty and against resistance. No evidence of swelling or deformity. No epitrochlear nodes palpated. Radial and brachial pulses equal bilaterally.

Breasts: Breasts symmetric and without dimpling or masses. Nipples without discharge. No palpable axillary lymph nodes. No masses felt in tail of Spence. Breasts palpated and examined while sitting with arms above head, while hands on hips leaning forward and while lying with hands raised above head.

Heart: Carotid upstrokes are brisk, without bruits. The point of maximal impulse is tapping. Good S1 and S2 auscultated. No murmurs or extra heart sounds. Regular rate, rhythm and intensity.

Abdomen: Abdomen is flat with active bowel sounds in all four quadrants. The abdomen is soft non-tender and non-distended. No rebound tenderness noted. No palpable masses. Liver and spleen not palpated. No Costovertebral angel tenderness. No aortic or renal artery bruits. Femoral pulses equal bilaterally.

Lower Extremities: Bilateral lower extremities symmetrical. Skin smooth warm and dry without hair. Bilateral dorsalis pedis pulses palpated. No edema or varicose veins noted. Patient able to perform active range of motion with hips, knees, ankles and feet without difficulty.

Neurological: Mental Status: Alert, relaxed, cooperative. Thought process coherent. Oriented to person, place, time and situation. Cranial Nerves: I – not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar – rapid alternating movements, finger-to-nose, heel-to-shin intact. Gait with normal base. Romberg – maintains balance with closed eyes. No pronator drift. Vertebrae midline. Pt. able to actively hyperextend, rotate and bend.

Pelvic: No inguinal adenopathy. External genitalia without erythema or lesions; no lesions or masses. No urethral discharge noted. Vaginal mucosa pink, with mucopurulent discharge noted in vaginal vault. Cervix pink and without contact bleeding. No cervical motion tenderness. Uterus anterior, midline, smooth, and not enlarged. No adenexal tenderness. No abdominal or pelvic pain during pelvic examination noted.

Laboratory Test Results:

Negative urine pregnancy test.

Wet Mount Prep (saline and KOH) – Normal transparent, clear epithelial cells with distinct borders, moderate amount of lactobacilli present. No pseudohyphae, yeast buds, clue cells, leukocytes or flagellate protozoan.

Whiff test – Negative

Vaginal pH – 4.0

Urine dip – Negative for protein, nitrates, leukocytes and glucose

Decision Point 2: Differential Diagnosis:

The differential diagnoses associated with intermenstrual bleeding include Chlamydia, Gonorrhea, Trichomonas, Pelvic inflammatory disease, appendicitis, urinary tract infection and interstitial cystitis. Five of these diagnoses can be eliminated based on the patient’s history, physical exam and laboratory findings. Trichomonas is eliminated because the patient denies any itching or the presence of a thin and frothy discharge. There was also an absence of flagellate protozoan on the wet mount prep.

Pelvic inflammatory disease and appendicitis can be excluded because the patient denies fever, rebound tenderness, cervical motion tenderness, nausea or vomiting. The patient also denies adenexal tenderness on palpation, which is common with PID (Loyd, Malin, Pugsley, Garcea, Garcea, Dennison et al, 2006).

The absence of urinary frequency, urgency and chronic pelvic pain eliminates the diagnosis of interstitial cystitis. The patient also denies any increase in symptoms preceding menstruation which also helps to exclude this diagnosis.

The urinary tract infection can be eliminated as a possible diagnosis based on the results of the urine dip test. The patient stated she had burning with urination but denied frequency or urgency. These findings exclude this diagnosis.

The remaining two differential diagnoses are gonorrhea and Chlamydia. Both diagnoses carry similar signs and symptoms and therefore must be closer evaluated.

Chlamydia - Is the most commonly diagnosed sexually transmitted infection worldwide with the highest rates of diagnosis between the ages of 16 and 24 (Flannigan, 2006). It is caused by a bacterium called Chlamydia trachomatis that is transmitted via oral, vaginal or anal intercourse. If left untreated Chlamydia infections can lead to serious sequelae of infections such as pelvic inflammatory disease, infertility and ectopic pregnancy (Grimshaw-Mulcahy, 2008). When the infection spreads to the uterus and fallopian tubes it can cause pelvic inflammatory disease which if left untreated will lead to infertility. During pregnancy Chlamydia can cause premature rupture of membranes, preterm birth or even spontaneous abortion during the first trimester of pregnancy (Grimshaw-Mulcahy, 2008). Due to the severity of complications it is imperative that a diagnosis is correctly made and treatment is facilitated.

Chlamydia is often under reported to the centers for disease control due to the fact that 80% of females and 50% of males are completely asymptomatic (Likis, 2006). The incubation period is 1-3 weeks after exposure before symptoms develop. If symptoms occur they can be different in men than in women. Men typically if symptomatic will complain of urethral discharge or dysuria (Flannigan, 2006). Another symptom reported by males with Chlamydia is unilateral pain and swelling in the scrotum (Likis, 2006).

While 80% of women with Chlamydia are asymptomatic, women with symptoms will often complain of bleeding during intercourse, irregular bleeding during periods or increased or abnormal mucopurulent discharge from the urethra (Flannigan, 2006). Symptomatic women sometimes also complain of lower abdominal pain, dysuria and fever. The cervix may also bleed more easily when rubbed with a swab or scraped with a spatula during a vaginal exam (Miller, 2006).

Chlamydia can be spread via anal intercourse as well resulting in an infection in the rectum leading to rectal pain, discharge or bleeding. This infection can also be spread through oral sex causing a throat infection.

Lab Abnormalities – The only lab abnormalities with Chlamydia is a positive nucleic acid amplification test (NAAT). This test can be obtained via a urine sample or a vaginal swab of the cervical os.

Individuals at high risk –

*Single persons between the ages of 16 and 24.

*Persons having a recent or frequent change in partners.

*Women who only use a non-barrier method of contraception (i.e. oral contraceptives or contraceptive implants).

*Persons who have had an STI in the past or present (Flannigan, 2006).

Associated Risks

Untreated cases of Chlamydia can cause severe reproductive consequences. It has

been noted as a major cause of pelvic inflammatory disease and infertility if left untreated (Waugh, 2007). Since 80% of females who are infected with Chlamydia are asymptomatic this has raised serious concerns in the United States as well as other countries. Other complications of Chlamydia infections include chronic pelvic pain and ectopic pregnancy (Madhogaria, Duru, Hart, Curran & Jungmann, 2006). When a Chlamydia infection is untreated infection can spread to reproductive organs such as the fallopian tubes, uterus and ovaries causing chronic pelvic pain or pelvic inflammatory disease. If these conditions continue without treatment the inflammation can cause permanent damage to these organs and lead to ectopic pregnancies or infertility (Centers for Disease Control and Prevention).

Chlamydia infections can lead to issues of infertility but it can also cause severe

complications during pregnancy. The infection can cause preterm rupture of membranes leading to preterm birth and some studies say it can also cause spontaneous abortions in the first trimester (Grimshaw-Mulcahy, 2008). If the pregnancy is carried through and the baby is born via a vaginal delivery the baby becomes at risk for conjunctivitis and early pneumonia from the exposure of the baby to the mother’s infected cervix (Grimshaw-Mulcahy, 2008).

Complications are rare in men but in cases where the infection spreads to the

epididymis it can cause pain, fever, and even sterility (Center for Disease Control and Prevention).

Gonorrhea

Gonorrhea is one of the oldest sexually transmitted infections in the United States (Schuiling & Likis, 2006). It can be transmitted by oral, anal or vaginal intercourse by the bacteria Neisseria gonorrhoeae. Individuals who have sex with multiple partners or unprotected intercourse are at greatest risk of transmission. Like Chlamydia, gonorrhea infections are asymptomatic in about 80% of females, but can lead to serious complications such as pelvic inflammatory disease if left untreated (Schuiling & Likis, 2006). Women who experience symptoms may notice a yellow or white vaginal discharge, burning or pain when urinating, urinary frequency, intermenstrual bleeding or postcoital bleeding, heavier or more painful periods, cramping or pain in the lower abdomen, fever or nausea (Forrest, 1999). Men infected with gonorrhea may experience yellow or white drip from the penis or stained underwear, burning and frequency of urinating, and pain and swelling in the testes (Forrest, 1999). Other signs of gonorrhea include pain or swelling in the knees or other joints, small red blisters on the skin or other cardiac related problems (Forrest, 1999).

Individuals with rectal gonorrhea may experience profuse purulent anal discharge, rectal pain, blood in the stool, rectal itching, fullness, pressure or pain (Schuiling & Likis, 2006). Viral Pharyngitis, a red and swollen uvula and pustule vesicles on the soft palate and tonsils may indicate an oral gonorrhea infection (Schuiling & Likis, 2006). Gonorrhea is diagnosed based on history of symptoms and a positive NAAT culture obtained from the cervix, rectum or pharynx.

Decision Point 3: Additional Diagnostic Tests:

Based on the history obtained from the patient it is suspected that Barbara has a Chlamydia infection. To confirm this diagnosis a nucleic acid amplification test (NAAT) is needed by obtaining an endocervical or urine sample (Schuiling & Likis, 2006). The endocervical sample is collected by inserting a swab into the cervical os and rotating it twice against the walls of the canal. The endocervical test is the preferred method of collection because it provides the highest sensitivity (Schuiling & Likis, 2006).

There are no other blood laboratory studies that are needed to diagnose Chlamydia. If however, other differentials could not be eliminated various labs could be obtained to help with elimination. A CBC could be drawn to check the white blood cell count. In conditions such as PID, UTI or cystitis an elevation in white blood cells could be expected. An abdominal CT could also be ordered to rule out appendicitis if the history did not rule out that differential diagnosis. A NAAT endocervical sample for gonorrhea and Chlamydia should be obtained to confirm a diagnosis.

Decision Point 4: Initial Management:

The presumed diagnosis of Chlamydia is based on Barbara’s symptoms of intermenstrual bleeding, yellowish colored discharge, mild lower abdominal pain, and burning with urination. Barbara’s physical exam revealed a soft, non-tender, non-distended abdomen with no rebound tenderness. Liver and spleen were not palpable. Barbara’s pelvic exam revealed no inguinal adenopathy. No lesions or masses on external genitalia. Mucopurulent discharge was noted in the vaginal vault. The cervix was pink without contact bleeding. The uterus was midline, smooth and not enlarged. No adenexal tenderness or abdominal pains were noted during the pelvic exam. These physical findings as well as the preliminary labs help to eliminate various differential diagnoses. The general management for Chlamydia is as follows:

Recommended Regimens for non-pregnant individuals:

➢ Azithromycin 1 gram orally in a single dose OR

➢ Doxycycline 100 mg orally BID X 7 days

Alternate Regimens for non-pregnant individuals:

> Erythromycin base 500 mg orally QID X 7 days OR

> Erythromycin ethylsuccinate 800 mg orally QID X 7 days OR

> Ofloxacin 300 mg orally BID X 7 days OR

> Levofloxacin 500 mg orally daily X 7 days

Recommended Regimens for pregnant females:

➢ Azithromycin 1 g PO X 1 OR

➢ Amoxicillin 500 mg PO TID X 7 days

Alternate Regimens for pregnant females:

➢ Erythromycin base 500 mg PO QID X 7 days OR

➢ Erythromycin base 250 mg PO QID X 14 days OR

➢ Erythromycin ethylsuccinate 800 mg PO QID X 7 days OR

➢ Erythromycin ethylsuccinate 400 mg PO QID X 14 days

Two considerations to take when prescribing the treatment for a Chlamydia infection is compliance and cost. If you fear compliance will be difficult for you patient it may be easier and more beneficial to choose the singe dose Azithromycin. Azithromycin can however be costly so a cheaper drug may need to also be considered (Likis and Schuiling, 2006).

If the patient is pregnant it is recommended that a test is repeated four weeks after treatment to check for a cure (Grimshaw-Mulcahy, 2008). All other individuals should be retested for a cure 3 to 4 months after initial treatment due to the high prevalence of repeat infections as well as the risk of complications increase with repeated infections (Schuiling & Likis, 2006).

Barbara is told to continue with her oral contraceptives. She is encouraged to use condoms in addition to her oral contraceptives to prevent against STI’s. Barbara is told that if either her gonorrhea or Chlamydia results come back positive she will be notified.

Decision Point 5: Final Diagnosis and Management:

The presumptive diagnosis of Chlamydia is confirmed with the NAAT endocervical sample result that came back positive for Chlamydia and negative for gonorrhea. Barbara was notified of the confirmed diagnosis and given a prescription for Azithromycin 1 gram orally once. She is instructed to abstain from sexual intercourse for 7 days. She is also instructed to have all sexual partners in the last 60 days referred for testing and treatment (Kirkland, 2006).

Two weeks after treatment Barbara reports that all her pervious symptoms are gone and she is feeling fine. She and her husband plan to start trying to have another child in the next 6 months. Barbara is instructed to return if symptoms return and in 3-4 months for a repeat screening due to the high risk of re-infection and her desire to conceive another child. She is given the following instructions regarding the transmission of sexually transmitted infections.

> Male condoms are encouraged for all sexually active individuals not in a monogamous relationship.

> Chlamydia infections pose possible complications during pregnancy if untreated.

> Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles could indicate a sexually transmitted infection and treatment should be initiated to reduce complications such as PID or infertility

> Some patients have sexually transmitted infections without any symptoms, so it is important to have routine screenings for sexually transmitted infections

> Annual STI screenings for sexually active women under the age of 25 is recommended

Figure 1 shows a case specific decision making algorithm for diagnosing a Chlamydia infection. Figure 2 provides a list of useful resources for patients and

healthcare providers regarding sexually transmitted infections

Case Study Summary:

In Barbara’s case she had complained of intermenstrual bleeding for two months while on oral contraceptives. She had additional symptoms of yellowish colored discharge and mild lower abdominal pain with a slight burning during urination. The initial differential diagnoses included Gonorrhea, Trichomoniasis, Pelvic inflammatory disease, Cystitis, Urinary tract infection and Chlamydia. The history, initial lab work and physical exam eliminated all of the differential diagnoses except Gonorrhea and Chlamydia. The NAAT endocervical sample testing for Gonorrhea and Chlamydia confirmed the diagnosis of Chlamydia.

Figure 1. Chlamydia Differential Decision Tree Algorithm

Intermenstrual Bleeding, Mild Abdominal Pain, Burning with urination, yellow mucopurulent discharge

Urine HCG

Positive = pregnancy Negative = Not pregnant

Wet Mount Prep

Normal transparent, clear epithelial cells, Positive Leukocytes and flagellate protozoan

with lactobacilli (normal) (Trichomoniasis)

Urine Dip

Negative – protein, glucose, nitrates & leukocytes Positive nitrates & leukocytes

(No UTI) (Probable UTI)

Pelvic Exam

Rebound Tenderness Positive Cervical Motion Tenderness

(Appendicitis) (PID)

NAAT Endocervical Sample

For Gonorrhea and Chlamydia

Positive Chlamydia Positive Gonorrhea

(Chlamydia) (Gonorrhea)

Figure 2. Resources

STD hotline 1-800-227-8922



Division of STD Prevention (DSTDP)

Centers for Disease Control and Prevention

std

CDC-INFO Contact Center

1-800-CDC-INFO (1-800-232-4636)

Email: cdcinfo@

CDC National Prevention Information Network (NPIN)

1-800-458-5231

E-mail: info@

References

Centers for disease control and prevention. (n.d.). Chlamydia – CDC Fact Sheet. Retrieved November 4, 2008, from

Flannigan, J. (2006, June 21). Chlamydia: the nurse’s role in diagnosis, treatment and health promotion. Nursing Standard (Royal College Of Nursing (Great Britain): 1987, 20(41), 59.

Forrest, K. (1999). Gonorrhea; Sexually transmitted disease [Brochure]. Santa Cruz, CA.

Grimshaw-Mulcahy, L. (2008, April). Now I know my STDs Part II: Bacterial and protozoal. The Journal for Nurse Practitioners. (2), 271-281.

Kirkland, L. (2006, December). New developments in the management of STDs. The Nurse Practitioner, 31(12), 12.

Lloyd, T., Malin, G., Pugsley, H., Garcea, A., Garcea, G., Dennision, A., et al. (2006, February). Women presenting with lower abdominal pain: A missed opportunity for chlamydia screening?. Surgeon, 4(1), 15-19.

Madhogaria, S., Duru, C., Hart, J., Curran, B., & Jungmann, E. (2006, February). Prevalence of Chlamydia trachomatis in sexual contacts of gonorrhea. International Journal Of STD & AIDS, 17(2), 130-132.

Miller, K. (2006, April 15). Diagnosis and treatment of Chlamydia trachomatis infection. American Family Physician, 73(8), 1411-1416.

Schuiling, K. & Likis, F. (2006). Women’s Gynecologic Health. Sudbury, Massachusetts: Jones and Bartlett.

Waugh, M. (2007, September). Sexually transmitted infections-microbial infections, 2007 update. Skinmed, 6(5), 242-244.

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