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Reproductive Case Study

The document presents two patient scenarios: Alexia, a 39-year-old female with pelvic pain and suspected STI leading to a diagnosis of Pelvic Inflammatory Disease and UTI, and Jeremy, a 35-year-old male with an inguinal hernia. Alexia received immediate treatment with antibiotics and was advised on follow-up care, while Jeremy's condition is being monitored with options for conservative management or surgical intervention if necessary. Both cases highlight the importance of diagnosis, treatment plans, and patient education.

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kammariaviksai
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58 views6 pages

Reproductive Case Study

The document presents two patient scenarios: Alexia, a 39-year-old female with pelvic pain and suspected STI leading to a diagnosis of Pelvic Inflammatory Disease and UTI, and Jeremy, a 35-year-old male with an inguinal hernia. Alexia received immediate treatment with antibiotics and was advised on follow-up care, while Jeremy's condition is being monitored with options for conservative management or surgical intervention if necessary. Both cases highlight the importance of diagnosis, treatment plans, and patient education.

Uploaded by

kammariaviksai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Patient Scenario #1

19
Alexia is 39 years old and is having 2
2
1
pelvic pain and started noticing vaginal
discharge. Last week, she started 1

seeing her urine discolored so she


decided to make a doctor’s
appointment. Alexia probably has an
STI, mostly chlamydia, gonorrhea or
trichomoniasis.
Progress note
Patient presents with complaints of pelvic pain, abnormal vaginal discharge, and discolored urine for the past week. Denies fever
or nausea. No history of recent trauma. No known drug allergies.
Objective:

● Vitals: BP 118/76, HR 82, Temp 98.6°F, RR 16, SpO₂ 98%

● Pelvic exam revealed mild cervical motion tenderness and purulent discharge.

● Urinalysis: positive for leukocyte esterase and nitrites; cloudy appearance.

● Vaginal swabs collected for STI panel.

● Pregnancy test: negative.

Assessment:
1. Suspected Pelvic Inflammatory Disease (PID) secondary to possible STI (pending lab results)

2. Urinary Tract Infection (UTI)


Progress note (continued)
Plan / Treatment:

● Medications administered in clinic:


Ceftriaxone 500 mg IM — 1 dose given in right gluteal region
Doxycycline 100 mg PO — first dose administered; 14-day course prescribed
Metronidazole 500 mg PO — first dose administered; 14-day course prescribed

● Supplies used:

Sterile gloves
Lubricant and speculum for pelvic exam
Alcohol swabs, syringe, and needle for IM injection
Collection swabs for STI testing
Urine specimen cup

● Patient response:
Tolerated pelvic exam and IM injection without complications. No adverse reactions noted post-medication. Patient verbalized
understanding of diagnosis and treatment plan. Discharge instructions reviewed, including medication adherence and sexual
abstinence during treatment.
● Follow-up:
Patient instructed to return in 1 week for re-evaluation or sooner if symptoms worsen. Advised to notify sexual partner(s) for evaluation
and treatment.
Patient Scenario #2: Patient Information
Jeremy, a 35 year old male, has Inguinal Hernia. Noted
symptoms are swelling in the penis region and
discomfort when sitting down.
Patient #2: Tests and Diagnosis

Physical examination: Inspection and palpation

A general practitioner (GP) will carefully examine the abdomen and groin area of
the patient for any bulges or swelling. Patient may also be asked to cough or strain
to make the hernia easier to detect.

Imaging test: Ultrasound

A sonographer will use an imaging technique that uses sound waves to create an
image of the hernia. This will help determine if the hernia is incarcerated (trapped)
or strangulated (blood flow to the trapped tissue cut off).
Patient #2: Treatment Options

Conservative Management: Watchful waiting and Lifestyle Modifications

Patient shall avoid any activities that can exacerbate the hernia. Patient will have
regular appointments at the general practitioner’s office to monitor the condition.

Surgical Treatment: Traditional Herniorrhaphy

If non-surgical treatments don’t work, patient will have open surgery in surgical
center. Process involves making an incision in the area of hernia and pushing the
bulging tissue into place, then reinforcing the weakened abdominal wall with
stitches to prevent hernia from recurring. Patient may stay in hospital for a whole
day.

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