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chlamydia trachomatis

The patient’s chief complaints of “Lower abdominal pain, painful urination, and vaginal discharge for two days” and pertinent physical assessment findings of malodorous thick yellowish-green vaginal discharge and cloudy urine appearance along with a positive nucleic acid amplification test (NAAT), lead to the diagnosis of Chlamydia. Moreover, which is caused by the gram-negative bacterium called chlamydia trachomatis.

Primary diagnosis: Chlamydial infection of Genito-urinary tract, unspecified – ICD- 10- A56.2

Treatment: The first recommended treatment for Chlamydia infection is antibiotic therapy. Therefore, I will order:

Sig # doxycycline 100 mg, orally, twice daily for seven days.

Dispense # 14

Refill # 0 

The alternative treatment regimens are a single dose of Azithromycin 1 gm orally or levofloxacin 500 mg, one tablet daily for seven days.

As per various research, doxycycline is effective for the treatment of chlamydia trachomatis infections of oropharyngeal, rectal, and urogenital sites. Although, in women, azithromycin is highly effective for urogenital chlamydial trachomatis infection.

Presumptively, all the sex partners in the last 60 days of the infected patient should also be treated.

The recommended treatment of chlamydial infection in pregnant women is a single dose of azithromycin 1 gm orally and substitute treatment of amoxicillin 500 mg orally three times a day for seven days. Furthermore, three months after the treatment, pregnant women should be retested for chlamydial infection. However, doxycycline is contraindicated in pregnancy, especially during the second and third trimesters.

Referral: No referral at this time.

Education:

I will instruct the patient and partner to abstain from sexual intercourse until the completion of a seven-day course of antibiotic therapy and the complete cure of the infection to prevent transmission or reoccurrences.

I will instruct the patient to contact the sex partner from the last three months so that they can get tested too.

Due to the higher chance of having multiple STIs, I will inform the patient that checking for other STIs such as HIV, syphilis, and herpes is essential.

I will inform the patient about the importance of regular screening for Chlamydia and other STIs because untreated Chlamydia can cause pelvic inflammatory disease and pregnancy complications.

I will offer behavioral counseling to the patient and her partner, which is an educational opportunity for clarifying their STI concern (USPSTF).

I will also educate about safe sex practices, such as the consistent use of condoms to minimize the risk of disease transmission and relapse of symptoms.

I will also instruct the patient to use strategies like motivational interviews to reduce risky behaviors.

I will inform the patient about the expedited partner therapy by the patient, pharmacy, or clinical specialist delivering the prescription to the partner.

I will also instruct the patient and partner to recheck chlamydia infection, three months after the treatment, due to its high probability of re-infection or reoccurrence.

Follow up: 

Follow up after seven days of antibiotic treatment.

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