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Chlamydia Plan of Care

Chlamydia Plan of Care

Final Project Plan of Care

A married couple presents to the office. They have requested to be seen together. The female is 28 years old and the male is 29 years old. They report they have not had any routine care since college. They are concerned that they can not pet pregnant.

CC. “We do not know where to begin so we thought we would have complete physicals. We know we need immunizations. Someone told us we should also get checked for chlamydia infections.“

Past medical history: None

Vital signs: Female: Blood pressure: 126/88; height, 5“; weight, 185 lbs.

Male: Blood pressure: 130/98; height 6 feet, weight 170 lbs

Questions:

1. What medical diagnoses apply to these

2. What additional subjective data do you think the patients will share?

3. What additional objective data will you be assessing for?

4. What National Guidelines are appropriate to consider?

5. What tests will you order*

6. Will you be looking for a consult*

7. Are there any legal/ethical considerations*

8. What is your plan of care?

9. Do any complementary therapies apply?

10. Are there any Healthy People 2020 objectives that you should consider?

11. What additional family/patient teaching is needed?

12. What billing codes would you recommend?

Final Project Plan of Care: Infertility Due To Chlamydia

A married couple presents to the offices having requested to be seen together. The female and male patients are aged 28 and 29 years old, respectively. Their chief complaint is that they cannot get pregnant and have not had any routine care since college. They would like to get a complete physical examination, immunizations, and chlamydia infection assessment. Infertility is the lack of conception despite unprotected sexual intercourse for a minimum of 12 months. Since the female patient is younger than 35 years, she will be considered infertile if there is no conception after 12 months of unprotected intercourse (WHO, 2019). The male patient is considered infertile since he has not produced and delivered enough quality sperm for initiation of pregnancy.

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Assessment

Subjective Assessment

First, the patients present with the chief complaints of inability to conceive and desire of having a child. The additional subjective data that will be shared by both partners is a comprehensive family, medical, and social history, which will uncover valuable information. The patient history data should bring about information about the infertility duration and if it is either primary or secondary; sexual intercourse frequency, regularity, frequency, and duration of menstruation as well as premenstrual symptoms (Dunphy, et al, 2019).  The female patient will provide information on vaginal discharge, trauma, pelvic infections, cervicitis, and surgery. She will also give substantial family history data, and general physical conditions, illnesses, allergies, intake of prescription and illicit drugs, as well as previous contraceptives use, duration, type, and any complications. The male patient will provide information on the history of mumps, trauma, herniorrhaphy, orchitis, diabetes mellitus, and exposure to x-rays and toxic substances. He will be questioned about his exercise patterns, drug intake, exposure to heat, infertility duration, and coitus frequency. Finally, both patients will provide data on maternal use of diethylstilbestrol should be recorded as it affects fertility.

Objective Assessment

The additional objective data will be assessed by conducting a complete physical examination of both partners, especially a thorough pelvic examination of the female patient, including size, mobility, shape, and uterus position. The physical examination includes weight, body mass index, blood pressure, pulse, enlargement, and presence of tenderness and nodules in the thyroid, breast characteristics and secretions, androgen excess, along with abnormality, secretion, or discharge of the vagina. Also, tenderness of the pelvis and abdomen will be assessed, enlargement, and masses of organs, adnexal masses, tenderness, Cul-de-sac mass, tenderness, and nodularity (American Society for Reproductive Medicine, 2012). The male patient’s examination will include testicular volume (lower than 15 milliliter is small) and testicular length (below 3.60 cm is small). The laboratory tests that will be ordered include complete blood count, T4, urinalysis, and thyroid-stimulating hormone. If the tests reveal negative findings, the infertility workup will start to determine the infertility causes.

Guidelines/Evidence

In the U.S., approximately 10-15% of couples have been experiencing difficulty conceiving a child after 12 months or more of trying. The American Society for Reproductive Medicine approximates that there are over 6 million couples with infertility problems, where 25% of fertile couples tend to conceive in one month of unprotected sexual intercourse. On average, the conception rate is 65% and 85% for six months and 12 months respectively. The World Health Organization categorizes infertility as a disease and the designation is supported by several professional associations like the American Medical Association (Berg, 2017) The 2020 ASRM national guidelines recommend that diagnostic testing for infertility ought to be started without delay after presentation of patients. There should be a past medical history, reproductive or sexual history, advanced ages and physical exam findings suggesting the probability of an impairment in reproductive function. Lastly, the American Family Physician offers guidance on evaluation and treatment among patients with risk factors for infertility or among females who are aged above 35 years.

Diagnostics

In the diagnostic stage, the easiest as well as the least intrusive infertility test, should be prioritized. One of the necessary tests that can be ordered to assess the ovulatory function is basal body temperature recording to identify follicular, luteal-phase, and ovulatory abnormalities. The additional records of coitus and serial BBT charts are used to designate retrospectively and the approximate timing for ovulation and whether sexual intercourse is happening at the right time to attain conception. Other tests include postcoital, serum progesterone measurement, serum LH, and immunoassay tests (Dunphy, et al, 2019). Moreover, the nucleic acid amplification tests should be conducted to assess the overall sensitivity, ease, and specificity of specimen transport for diagnosis of the gonococcal and hlamydial infections (Papp, et al.,2014) A systematic female evaluation will include assessment of the hypothalamic-pituitary axis regarding ovulatory function, progesterone, prolactin, FSH, and LH levels, as well as the examination of vaginal discharge. Besides, magnetic resonance and hysterosalpingogram imaging could be done to assess the structure and functioning of ovaries, cervix, uterus, and fallopian tubes. A more sensitive test is laparoscopy to detect tubal abnormalities if there are abnormal findings from hysterosalpingogram.

The semen analysis is one of the diagnostic studies of the male patient. It should also be conducted in the early stage of the couple‚Äôs evaluation prior to the female invasive testing. The semen analysis should be done within a day after donation, where the normal sperm morphology could be as low as 15 to 20 percent with favorable results. The progressive sperm mobility, viability, semen pH, Cellular debris and agglutination, and antibodies should be assessed. The male patient’s evaluation will include a minimum of two semen analyses for confirmation or ruling out the seminal deficiency after assessing serum FSH, LH, and testosterone levels.

Differential Diagnosis

Infertility is a complex medical issue that is caused by many factors. The evaluation will reveal a positive diagnosis when the vital components prerequisite for normal fertility among women is absent. In the case of normal fertility, the cervical mucus should favorable for the survival of sperms and permit passage into the upper genital tract between the cervix and fallopian tubes. The patient’s fallopian tubes should be patent and contain normal fimbria to allow peristaltic movement towards the uterus to facilitate regular transportation and interactions of sperm and ovum. Also, the ovaries should produce and discharge healthy ovum in a well-timed manner, and no obstructions should be between the ovary and fallopian tube. Lastly, normal fertility occurs when the endometrium is in the normal physiological state that allows for blastocyst implantation and sustenance of normal development and growth.

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The common causes of tubal infertility arise from antecedent pelvic inflammatory disease, occasioned mostly by Chlamydia trachomatis and Neisseria gonorrhoeae (O’Neil, et al., 2011). Chlamydia infection should be differentiated from other types of genital tract infections like gonorrhea, bacterial vaginosis, syphilis, vaginal candidiasis, trichomonas vaginalis, and¬†mycoplasma¬†infections. The lab findings consistent with positive Chlamydial infection diagnosis include absolute increased eosinophil count (greater than 400cells/mm3, greater than 5 WBCS per high power field, and increased¬†leukocyte¬†count (Kamberg, 2016). The transvaginal ultrasound findings suggestive include thickened and dilated¬†fallopian tubes, incomplete septa, enlarged vascularity, and cogwheel sign.

Treatment Plan

The treatment principle is assisting the couple in attaining pregnancy in the natural age-related reduction in fecundity among females. Some lifestyle changes can escalation the chances of becoming pregnant before the recommendation of other medical interventions (Vause, et al., 2010). The female patient should restrict her caffeine intake to less than 250 mg daily since increased coffee consumption delays conception and increases the risks for miscarriages and preterm labor. Similarly, the patient should limit the alcohol intake to over four drinks weekly as it affects fertility among women. Besides, the couple should increase sexual intercourse up to 2-3 times weekly. Since the woman’s BMI is 31.5, she should attempt to lose weight to normal levels to aid restoring ovulation as the first-line therapy. Clomiphene has proven as an effective method for induction of ovulation in women who have polycystic ovary syndrome. Adding 1,500 to 1,700 milligrams of metformin daily might increase the changes of ovulation and pregnancy, however it does not considerably increase live birth rates using only clomiphene,

The mainstay of treatment therapy for chlamydia is using antimicrobial treatment with doxycycline (100 milligrams PO for seven days). For the treatment of infertility, the clinician could use ovulation induction agents that could lead to an increase the risks of multiple pregnancy, ovary hyperstimulation syndromes, and thrombosis (Lindsay & Vitrikas, 2015). Thus, aromatase inhibitors can be recommended, such as letrozole and anastrozole, as they have a shorter half-life and minimal antiestrogen effects. Ovarian drilling, can aid in inducing ovulation. Alternatively, intrauterine insemination high in the uterus just before ovulation can be done based on the LH measurement could be used as an effective method before in vitro fertilization. With the high intrauterine insemination, the likelihood of pregnancy can be improved using simultaneous treatment with clomiphene for 3 to 6 cycles, or at least three cycles of gonadotropin injections.

Evaluation

The couple are recent sex partners as they have maintained sexual contact in 60 days preceding the Chlamydia diagnosis, thus they should be referred for further evaluation, tests, and probable dual treatment. If the patient who does not achieve ovulation after 3-6 cycles can be referred to the infertility specialists for further evaluation and treatment. If the couple does not conceive after the treatment following six cycles with the documented ovulation can be referred infertility specialist (American Society for Reproductive Medicine, 2013). The last resort will be IVF, embryo transfer, or gamete intra-fallopian transfer to achieve pregnancy.

Healthy People 2020

One of the Healthy People goals is an improvement of pregnancy planning, spacing, and the prevention of unintentional pregnancies. Access to reproductive and sexual health enhances the quality of health care for both men and women. Family planning is a notable public health achievement of the century that allows a person to attain desirable spacing of birth and size, which contributes to better health outcomes for the children, females, and their families (Lowdermilk, et al., 2020). The family planning services include contraception, pregnancy testing, preconception, infertility, STD and HIV services, patient education and counseling, and breast and pelvic exams and cancer screening.

                                                   Patient/Family Teaching

The infertile couple will need adequate support, advocacy, education, and assistance in decision making. The treatment options should be offered in a non-judgmental manner to aid in their decision making. There is a need to teach the couple to monitor the various signs and timing of ovulation and the timing for sexual intercourse in the cycle before initiation of extensive testing. Furthermore, to avoid chlamydia reinfection, the couple should be instructed on the need to desist from unprotected sexual intercourse for one week after the treatment and resolution of symptoms. There should be an emphasis on teaching self-care using coping strategies that will help the patient regain control using stress-reduction techniques like exercise and relaxation techniques and family-centered care.       

Billing

The health services used in the evaluation of potential infertility among patients are covered under the U.S standard benefits. The services covered under the diagnostic services to are viewed medically necessary when they are performed exclusively to determine the fundamental etiology of infertility. To suitably bill for the patient’s diagnostic testing, one can use the individual CPT codes that are listed within the CPT code ranges 89300-89330, 89258-89259, 89250-89255, 58740-58770, 58321-58350, and 58970- 58976 under the Billing and Coding section.

Follow up

The clinician should provide referrals to other consultants to assist and offer support to the infertile couple. After the examination and counseling concerning both timing and frequency and timing of sexual intercourse, the couple could be advised to proceed with further tests and treatment in a fertility clinic.

References

American Society for Reproductive Medicine (March 01, 2020) Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertility and Sterility, 113, 3, 533-535. Retrieved from https://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/practice-guidelines/for-non-members/definitions_of_infertility_and_recurrent_pregnancy_loss.pdf

American Society for Reproductive Medicine¬†Practice Committee (2013). Use of clomiphene citrate in infertile women: a committee opinion.¬†Fertility Sterile.100, 2, 341‚Äď348.

American Society for Reproductive Medicine (August 01, 2012). Diagnostic evaluation of the infertile female: a committee opinion. Fertility and Sterility, 98, 2, 302-307.

Berg, S. (2017, June 13). American Medical Association backs global health experts in calling infertility a disease. Retrieved from https://www.ama-assn.org/delivering-care/public-health/ama-backs-global-health-experts-calling-infertility-disease

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.

Kamberg, M.-L. (2016). Chlamydia. New York : Rosen Publishing.

Lindsay, T.J. & Vitrikas, K.R (2015, Mar 1). Evaluation and Treatment of Infertility. American Family Physician, 91, 5,308-314.

Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F. (2020).¬†Maternity & women’s health care. St. Louis, Missouri: Elsevier.

O’Neil, D., Doseeva, V., Rothmann, T., Wolff, J., & Nazarenko, I. (January 01, 2011). Evaluation of Chlamydia trachomatis and Neisseria gonorrhoeae Detection in Urine, Endocervical, and Vaginal Specimens by a Multiplexed Isothermal Thermophilic Helicase-Dependent Amplification (tHDA) Assay ‚ĖŅ.¬†Journal of Clinical Microbiology,¬†49,¬†12, 4121-4125.

Papp, J. R., Schachter, J., Gaydos, C. A., & Van, D. P. B. (March 14, 2014). Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae ‚ÄĒ 2014.¬†Morbidity and Mortality Weekly Report: Recommendations and Reports,¬†63,¬†2, 1-19.

Vause, T. D. R., Cheung, A. P., Sierra, S., Claman, P., Graham, J., Guillemin, J.-A., LapenseŐĀe, L., … Wong, B. C.-M. (January 01, 2010). Ovulation Induction in Polycystic Ovary Syndrome :No. 242, May 2010.¬†International Journal of Gynecology and Obstetrics,¬†111,¬†1, 95-100.

World Health Organization (2019). Infertility definitions and terminology. Retrieved from: http://www.who.int/reproductivehealth/topics/infertility/definitions/en

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