Comprehensive Assessment of a Patient with Chlamydia
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.
Comprehensive Assessment of a Patient with Chlamydia
Date of Visit: 25/10/2014
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
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
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
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
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.
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.
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.
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.
A: Primary 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
Respiratory chlamydioses is tested using assay for changes in antibody titer .
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).
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 &
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
Follow-up: A follow-up evaluation may be done in 4 weeks to determine if the infection has
been cured (Alexander, 2010).
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.
Chernecky, C. C., & Berger, B. J. (2013). Laboratory tests and diagnostic procedures. St. Louis,
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
Alexander, L. L. (2010). New dimensions in women’s health. Sudbury, Mass: Jones and Bartlett