Urinary tract infections are a group of infections that damage a part of a urinary tract of a patient and may lead to adverse outcomes. Among patients that have these infections, adolescents represent a particular risk group because there is a possibility of development of different complications in them. Moreover, the fact that adolescents depend on their parents’ decisions and authority may complicate the procedures of assessment. For example, an adolescent patient can conceal the information that may be important, which will cause confusion. Also, there is a possibility that the information provided by a young and his or her parents may differ in details, and this may also mislead medical staff. This paper discusses these issues by presenting a case of assessment of an adolescent patient examined during the last four weeks. In a form of a SOAP Note, it identifies subjective and objective details of assessment, as well as its results, and provides a plan of treatment and reflection notes. The presented case is an example of assessment and treatment of an adolescent female patient that has cystitis associated with sexual activity. The discussed assessment procedures and methodology of treatment would be useful for any person dealing with an adolescent that has a urinary tract infection in a clinical and non-clinical setting.
Subjective assessment is an important part of a clinical analysis because it allows identifying the basic reasons that caused development of an infection or disease in a person. The framework of the subjective assessment should be thoroughly planned in order to obtain information that is critical to recognizing a patient’s condition and deciding on an appropriate treatment. In order to get the most relevant answers, a semi-structured interview that considered different domains of the patient’s life was proposed to the child and the parents. This form of subjective assessment was selected because experts claim that it allows revealing the basic health issues in the most relevant way, promoting further effective clinical decisions (Bahl, Davison, & Dollman, 2015). The sections of the interview focused on such aspects as the patient’s physic and mental condition, the presence of previous and chronic problems with health including urinary tract infections. In addition, some of the questions included a false scale for revealing a probability of either a child or the parents giving deliberate non-true answers. Thus, a 17-year-old female patient named Tina (the name is deliberately changed) complained about painful urination, especially in the nighttime. Besides, she reported having an increased body temperature with periodic reoccurrence without any direct indicator of a respiratory or another disease. Her other complaint was feeling weak and irritated during the day because of which she lost concentration at her classes and had bad academic progress. In addition, Tina was worried about the fact that she often felt that she had to urinate although often she was unable to do it. As for previous cases of having any urinary tract infection, Tina reported having cystitis about half a year ago. Further questions revealed that she had her first sexual intercourse about 7-8 months ago. As a result, there was a probability that this was the case of a reoccurring urinary tract infection (UTI) that had been initiated by the sexual contact. In this regard, experts state that in such cases, there is a range of bacterial infections that cause an inflammatory response of the organism after sexual intercourse in adolescents (Dason, Dason, & Kapoor, 2011). Further answers of Tina’s parents revealed that they were aware of the issues indicated by the patient. They also reported that the cystitis was cured because Tina was administered antibiotics. The false scale in both interviews indicated that neither the patient nor her parents deliberately misled the medical staff when answering the questions. At the same time, Tina and her parents demonstrated no awareness of the basic causes of UTI in adolescents and the measures of their prevention.
The next stage of the patient’s assessment included physical assessment during which mostly negative physical exam findings were discovered. Tina’s body temperature during the assessment was 38 degrees Centigrade; she felt pain in her lower stomach. Moreover, she had vaginal discharge with odor, which is not typically associated with cystitis but may indicate that a patient has chlamydia infection (Frej-Mądrzak, Teryks-Wołyniec, Jama-Kmiecik, Sarowska, & Choroszy-Król, 2015). Further diagnosis of urine consistency revealed that the patient’s urine was not transparent and had a presence of gluey-like substances. The vaginal smear analysis demonstrated the presence of Chlamydia Trachomatis, which was proved both by endocervical and vulvovaginal sample analyses (Stewart, Schoeman, & Wilson, 2013). The positive physical exam findings were visual as there was no indicator of the damaged tissue, but only slight irritation. This was caused by patient washing in a shower from three to five times a day and used other relevant hygienic practices in an attempt to remove the odor (Das et al., 2015). Other procedures revealed that the patient’s bladder was not infected with pathogenic bacteria unlike her urinary tract, which triggered urination.
Furthermore, the patient developed several psychosocial issues, which included conflicts with classmates because of constant irritation and alienation. She also reported discomfort and tension and feeling ashamed of the need for urinating more often than healthy people do. Such problems are typical for females with UTI, who often feel more embarrassed and uncomfortable with their physical state than men (Anuradha & Ramesh, 2015). Therefore, Tina’s infection was a powerful stressor and drained her both physically and emotionally, deteriorating the quality of her life. The problems of physical health in this case also aggravated the academic success of the patient, which increased anxiety and irritation. However, although the patient was stressed and reported having psychosocial problems, there were no signs that she experienced depression, which was a positive finding.
Adequate diagnosing of the patient is one of the most critical factors that directly influence the promotion of the patient’s treatment and recovery. The performed subjective and objective analyses revealed the presence of both physical and mental health problems caused by a urinary tract infection. However, due to the fact that there was a broad range of infections caused by different pathogenic microorganisms, the selection of the primary diagnosis required advanced analytical procedures. This process started with selecting three differential diagnoses associated with the patient’s condition and results of the physical examination and swabs analysis. The first and the primary diagnosis was Chlamydia Trachomatis, which was proved by the vaginal swab analysis. Other diagnoses included reoccurring or chronic cystitis caused by the physical damage of vaginal tissue and further inflammation of the urinary tract. It was possible that the patient had a combination of these infections because of the fact that she had cystitis less than half a year ago. In this case, there was a need for instructing the patient and her parents about the methods that would allow avoiding the infection to reoccur. Last, the patient might have thrush or chronic vulvovaginal candidiasis, which was caused by a form of pathogenic bacteria, Candida that may be of various types. It was associated with similar symptoms as vulvovaginal itch, discomfort, increased vulvovaginal secretory function associated with odor, and negative psychosocial outcomes (Hong, Dixit, Fidel, Bradford, & Fischer, 2014). However, the analysis of the vaginal swab and its history demonstrated that the patient had no indicator of having bacteria of Candida type, which was why this diagnosis was false. Therefore, the primary diagnosis for the patient was a combination of chlamydial infection and cystitis, which were mostly caused by sexual intercourse in the young age. Moreover, there was a probability that the patient obtained reinfection either because of poor awareness of urinal tract and genital diseases or the infected sexual partner.
Planning is an important component of any medical treatment due to the fact that optimized planning allows reducing assessment time increasing its efficacy. In order to provide a relevant diagnosis, the assessment, and diagnostics procedures started with an interview that allowed revealing secondary indicators of a UTI. Furthermore, physical assessment allowed narrowing the range of the possible diseases and focusing on the three ones that were recognized as the most probable. Last, the laboratory analysis of a vulvovaginal swab of the patient allowed finding the source of infection. Further initiatives were associated with treatment and management of the health problem, which consisted of two parts. The first one was directed at achieving positive short-term results in order to mitigate the occurrence of swelling, pains, increased quantity of urination acts, and the overall patient’s irritation. In order to achieve it, the patient was prescribed azithromycin and scheduled for a follow-up visit after six months of treatment (Geisler, Lensing, Press, & Hook, 2013). In addition, there was a need for calling the patient’s sexual partner due to the suspicion of the presence of a shared chlamydia infection that might lead to reinfection of the patient or spontaneous resolution of the disease (Geisler et al., 2013). The need for treating a sexual partner of the patient with a UTI or sexually transmitted disease is well-known in medicine because of the behavioral risk data that leads to shared reinfection (Lewis et al., 2014). In addition, there was a need for administering such sedatives as Lemon Balm and Valerian that would mitigate the problem of the patient’s irritation. These medicines were selected because of their natural origin as they are made of plants and produce an efficient pharmacological effect (Pineau, Legros, & Mattei, 2016). In addition, they were selected in order to avoid administering barbiturates and other strong sedatives and tranquilizers that may lead to addiction and adverse psychological effects in adolescents (Juan, 2015). Furthermore, both the patient and the parents were given information about the causes of UTI and sexually transmitted diseases and the methods of their prevention. This knowledge appeared to be critical for them due to the fact that they demonstrated no awareness of this information during the interview. The provided knowledge was aimed at the improvement of positive long-term effects on the patient’s health. Also, treatment and education of the similar issues of the patient’s sexual partner would assist achieving positive long-term goals of Tina’s treatment. The follow-up procedures require performing similar stages of assessment that include interviewing, physical and laboratory assessment in order to adequately trace the process of the patient’s recovery. In case the described plan is validated, it is possible to assure the patient’s recovery and significant improvement of the quality of her life.
The phase of reflection is important for any study because it allows revealing its strong and weak points. My “aha” moment in this study was facing the need for laboratory assessment. Before these procedures, I struggled when deciding between two diagnoses that are associated with similar results of the physical examination. Without any doubt, the laboratory analysis was highly important for the study because it allowed exploring the exact pathologic microorganism. The results of the analysis gave me a clear clinical picture of the infection, and I started selecting the most relevant methods of treatment. Besides, I recognized that when treating UTIs, it is important to achieve long-term goals because this kind of infection often reoccurs in female patients due to their physiology (Anuradha & Ramesh, 2015). This case made me recognize that I have a valid plan for diagnosis and treatment of patients with UTI, but each patent is unique, which is why I may need different solutions. For instance, a patient may require different types of antibiotics that are more efficient against his or her infection. Moreover, in case a patient is a male, the clinical picture would be completely different because of physiological diversity and other factors. However, in the case with similar patient evaluation, I would use the designed plan with possible minor differences depending on the diagnosis.
In summary the analyzed case is an example of widespread statistics with adolescents having urinary tract infections and chlamydia infection in particular. In the case with Tina, the female patient aged 17, this infection was caused by a sexual intercourse with an infected partner and further aggravated with chronic cystitis. The positive aspect of the assessment procedures was that the patient and her parents actively collaborated with the physician. The diagnosis was proved by the analysis of the patient’s medical records, semi-structured interview, physical assessment, urinal analysis and vaginal swab. The methods of treatment included administration of antibiotics supported by hygienic measures and treatment of the patient’s sexual partner. In addition, Tina and her parents were instructed about the causes of urinary tract and genital diseases and the methods of their prevention. These measures are associated with increased efficacy because they allow the patients to avoid reoccurrence of disease and enhance one’s knowledge of the required hygienic procedures that grant positive health outcomes. Every mentioned procedure in the case was adequately planned in order to meet the demands of the contemporary medicine. As a result, it allowed producing a relevant diagnosis and valid treatment initiatives that enable the patient’s positive short and long-term outcomes.