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Chlamydia
Chlamydia: Case Study Decision Tree
Nursing 706 Otterbein College
Lisa J. King
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Chlamydia: Case Study and Decision Tree
By Lisa King, RN, BSN
Chlamydia is the most commonly diagnosed sexually transmitted infection
worldwide with an increased prevalence in women between the ages of 15 and 24
years old. It is transmitted by unprotected vaginal, anal and oral sex. Chlamydia is
found to contribute to several reproductive complications such as pelvic
inflammatory disease, chronic pelvic pain, ectopic pregnancy and infertility. Using
a case study format this article will examine differential diagnoses and treatments
for Chlamydia.
Chief Complaint: “I have been bleeding between my periods for the past two months.”
History of Present Illness: Barbara is a married, white 22 year old female. She started
her menses at age 9 and reports having problems with bloating, cramping, irritability and
emotional changes during her periods. She states her periods are 4-5 days in length with
a moderate amount of bleeding and have been regular since she started the birth control
pill at age 18. Barbara states that for the past two months she has experienced bleeding
between her periods. She denies pain or bleeding with intercourse. She complains of a
moderate amount of yellowish colored discharge without odor. Barbara states that she
has mild lower abdominal pain at times and slight burning with urination, but denies
urinary urgency or frequency. She denies vaginal itching or fever. Barbara states that
these symptoms are not any worse or better in relation to her regular menstrual cycle and
states that she has not tried any measures to relieve these symptoms.
Current Medications:
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Levora birth control pills once daily
Over the counter multivitamin daily
Tylenol as needed for abdominal cramping
Past Medical History: Barbara has a past medical history of ovarian cysts in 2004. She
states she was started on birth control pills and has since had no problems. Barbara also
has a history of kidney stones in 2006 and a Chlamydia infection in August of 2007. In
2007 Barbara also had an abnormal PAP exam showing LSIL which was followed by a
colposcopy procedure. No further medical intervention was needed for this incident.
Allergies: PCN – rash; Zithromax – rash
Past Surgical History: Colposcopy procedure 6/29/07. No other surgical procedures
noted.
Family History:
Mother 43 years old with type II diabetes, has regular periods
Father 45 years old alive and well with history of HTN
Maternal grandmother with a history of hyperlipidemia
Maternal grandfather with a history of HTN, hyperlipidemia and stroke
Paternal grandmother alive and well
Paternal grandfather died at age 64 of an MI
Social History: Barbara is a 22 year old married mother of one. She had a two year old
son via an uncomplicated vaginal delivery in May of 2006. She and her husband plan on
trying to have another child in the next year. She has had two total sexual partners in her
lifetime, one in the past year. Barbara admits to drinking socially, once every two weeks
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and denies the use of tobacco or other illegal drugs. Barbara works at an insurance
company part time and enjoys spending her extra time with her son.
Decision Point 1: Focused History, Physical Examination, Laboratory Tests
History: The history is focused at identifying the cause of Barbara’s breakthrough
bleeding. The following questions are to determine the cause of her irregular bleeding
patterns.
 When was your last regular menstrual cycle?
 Is there a chance you could be pregnant?
 Do you have any bleeding or pain after intercourse?
 Do you notice a foul vaginal odor?
 Do you have any abdominal pain?
 Are you taking any other herbs or medications?
 Describe your relationship with your husband. Do you get along well? Any areas
of conflict or abuse?
 Have you ever been sexually abused?
 Are you experiencing any excessive discharge or itching?
 Do you notice any burning with urination?
 Have you had any nausea or vomiting?
 Have you had a fever?
 Have you ever had an abnormal Pap smear?
 Have you ever had a CT scan of the abdomen or an abdominal ultrasound?
Physical Exam FindingsVital Signs:
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 Blood Pressure: 120/74 mm Hg in the right arm, sitting
 Hear rate: 84 beats per minute
 Respiratory rate: 18 breaths per minute
 Temperature: 98.8 degrees F
 Height: 5 feet, 1 inch; weight: 157 pounds; body mass index (BMI): 30 kg/m
General: Barbara is a pleasant, well groomed 22 year old female. She is in no apparent
distress. She asks questions appropriately and makes direct eye contact with the nurse
practitioner student. She has a steady gait with no physical deformities. She is able to
ambulate without assistance. Her speech is clear and hearing is normal.
Skin: Skin color pink. Skin warm and dry. Nails without clubbing or cyanosis. No rash,
petechiae, or ecchymoses.
Head and Face: The skull is normocephalic/atraumatic. Medium reddish brown hair is
evenly distributed, with average texture. No alopecia or balding spots noted. Facial
expression appears happy, symmetrical.
Eye: External eyes appear symmetrical in shape and position. Peripheral vision intact.
Extraocular muscle movement conjugate, without nystagmus or lid lag. Sclera white,
conjuctiva pink. Pupils are 3 mm constricting to 2 mm, equally round and reactive to
light and accommodations.
Ear: Acuity good to whispered voice.
Nose: External appearance symmetrical with no deformities. No sinus tenderness.
Mouth and throat: Lips pink and moist without cracking or ulcerations. Buccal mucosa
without incidence. Tongue pink, symmetrical with no ulceration. No white or erythemic
areas noted under tongue or on floor of the mouth. Hard and soft palate intact. Anterior
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and posterior pillars, uvula, tonsils and pharynx pink without exudates, swelling or
ulcerations. Uvula vibrates but remains midline upon patient speaking Ahh. Oral mucosa
pink, dentition.
Neck: Neck symmetrical with no masses or scars. Trachea midline. Neck supple;
thyroid palpable without notches or masses. No palpable cervical, preauricular, posterior
auricular, occipital, tonsillar, submandibular, submental, supraclavicular lymph nodes.
Carotid pulses palpated, no bruit auscultated. Range of motion and muscle strength
against resistance without incident.
Chest, Posterior: No areas of tenderness or abnormalities noted on posterior chest.
Thorax is symmetric with symmetrical expansion. Breath sounds vesicular; no rales,
wheezes, or rhonchi. No adventitious lung sounds audible.
Chest, Anterior: Anterior thorax symmetric with good expansion. Lungs resonant.
Breath sounds equal and clear bilaterally with no rales, wheezes or rhonchi.
Upper Extremities: Patient able to perform active range of motion of hands, arms,
elbows, and shoulders without difficulty and against resistance. No evidence of swelling
or deformity. No epitrochlear nodes palpated. Radial and brachial pulses equal
bilaterally.
Breasts: Breasts symmetric and without dimpling or masses. Nipples without discharge.
No palpable axillary lymph nodes. No masses felt in tail of Spence. Breasts palpated and
examined while sitting with arms above head, while hands on hips leaning forward and
while lying with hands raised above head.
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Heart: Carotid upstrokes are brisk, without bruits. The point of maximal impulse is
tapping. Good S1 and S2 auscultated. No murmurs or extra heart sounds. Regular rate,
rhythm and intensity.
Abdomen: Abdomen is flat with active bowel sounds in all four quadrants. The
abdomen is soft non-tender and non-distended. No rebound tenderness noted. No
palpable masses. Liver and spleen not palpated. No Costovertebral angel tenderness. No
aortic or renal artery bruits. Femoral pulses equal bilaterally.
Lower Extremities: Bilateral lower extremities symmetrical. Skin smooth warm and dry
without hair. Bilateral dorsalis pedis pulses palpated. No edema or varicose veins noted.
Patient able to perform active range of motion with hips, knees, ankles and feet without
difficulty.
Neurological: Mental Status: Alert, relaxed, cooperative. Thought process coherent.
Oriented to person, place, time and situation. Cranial Nerves: I – not tested; II through
XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar –
rapid alternating movements, finger-to-nose, heel-to-shin intact. Gait with normal base.
Romberg – maintains balance with closed eyes. No pronator drift. Vertebrae midline. Pt.
able to actively hyperextend, rotate and bend.
Pelvic: No inguinal adenopathy. External genitalia without erythema or lesions; no
lesions or masses. No urethral discharge noted. Vaginal mucosa pink, with mucopurulent
discharge noted in vaginal vault. Cervix pink and without contact bleeding. No cervical
motion tenderness. Uterus anterior, midline, smooth, and not enlarged. No adenexal
tenderness. No abdominal or pelvic pain during pelvic examination noted.
Laboratory Test Results:
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Negative urine pregnancy test.
Wet Mount Prep (saline and KOH) – Normal transparent, clear epithelial cells
with distinct borders, moderate amount of lactobacilli present. No pseudohyphae, yeast
buds, clue cells, leukocytes or flagellate protozoan.
Whiff test – Negative
Vaginal pH – 4.0
Urine dip – Negative for protein, nitrates, leukocytes and glucose
Decision Point 2: Differential Diagnosis:
The differential diagnoses associated with intermenstrual bleeding include
Chlamydia, Gonorrhea, Trichomonas, Pelvic inflammatory disease, appendicitis, urinary
tract infection and interstitial cystitis. Five of these diagnoses can be eliminated based on
the patient’s history, physical exam and laboratory findings. Trichomonas is eliminated
because the patient denies any itching or the presence of a thin and frothy discharge.
There was also an absence of flagellate protozoan on the wet mount prep.
Pelvic inflammatory disease and appendicitis can be excluded because the patient
denies fever, rebound tenderness, cervical motion tenderness, nausea or vomiting. The
patient also denies adenexal tenderness on palpation, which is common with PID (Loyd,
Malin, Pugsley, Garcea, Garcea, Dennison et al, 2006).
The absence of urinary frequency, urgency and chronic pelvic pain eliminates the
diagnosis of interstitial cystitis. The patient also denies any increase in symptoms
preceding menstruation which also helps to exclude this diagnosis.
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The urinary tract infection can be eliminated as a possible diagnosis based on the
results of the urine dip test. The patient stated she had burning with urination but denied
frequency or urgency. These findings exclude this diagnosis.
The remaining two differential diagnoses are gonorrhea and Chlamydia. Both
diagnoses carry similar signs and symptoms and therefore must be closer evaluated.
Chlamydia - Is the most commonly diagnosed sexually transmitted infection
worldwide with the highest rates of diagnosis between the ages of 16 and 24 (Flannigan,
2006). It is caused by a bacterium called Chlamydia trachomatis that is transmitted via
oral, vaginal or anal intercourse. If left untreated Chlamydia infections can lead to
serious sequelae of infections such as pelvic inflammatory disease, infertility and ectopic
pregnancy (Grimshaw-Mulcahy, 2008). When the infection spreads to the uterus and
fallopian tubes it can cause pelvic inflammatory disease which if left untreated will lead
to infertility. During pregnancy Chlamydia can cause premature rupture of membranes,
preterm birth or even spontaneous abortion during the first trimester of pregnancy
(Grimshaw-Mulcahy, 2008). Due to the severity of complications it is imperative that a
diagnosis is correctly made and treatment is facilitated.
Chlamydia is often under reported to the centers for disease control due to the
fact that 80% of females and 50% of males are completely asymptomatic (Likis, 2006).
The incubation period is 1-3 weeks after exposure before symptoms develop. If
symptoms occur they can be different in men than in women. Men typically if
symptomatic will complain of urethral discharge or dysuria (Flannigan, 2006). Another
symptom reported by males with Chlamydia is unilateral pain and swelling in the
scrotum (Likis, 2006).
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While 80% of women with Chlamydia are asymptomatic, women with symptoms
will often complain of bleeding during intercourse, irregular bleeding during periods or
increased or abnormal mucopurulent discharge from the urethra (Flannigan, 2006).
Symptomatic women sometimes also complain of lower abdominal pain, dysuria and
fever. The cervix may also bleed more easily when rubbed with a swab or scraped with a
spatula during a vaginal exam (Miller, 2006).
Chlamydia can be spread via anal intercourse as well resulting in an infection in
the rectum leading to rectal pain, discharge or bleeding. This infection can also be spread
through oral sex causing a throat infection.
Lab Abnormalities – The only lab abnormalities with Chlamydia is a positive nucleic
acid amplification test (NAAT). This test can be obtained via a urine sample or a vaginal
swab of the cervical os.
Individuals at high risk –
*Single persons between the ages of 16 and 24.
*Persons having a recent or frequent change in partners.
*Women who only use a non-barrier method of contraception (i.e. oral
contraceptives or contraceptive implants).
*Persons who have had an STI in the past or present (Flannigan, 2006).
Associated Risks
Untreated cases of Chlamydia can cause severe reproductive consequences. It has
been noted as a major cause of pelvic inflammatory disease and infertility if left untreated
(Waugh, 2007). Since 80% of females who are infected with Chlamydia are
asymptomatic this has raised serious concerns in the United States as well as other
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countries. Other complications of Chlamydia infections include chronic pelvic pain and
ectopic pregnancy (Madhogaria, Duru, Hart, Curran & Jungmann, 2006). When a
Chlamydia infection is untreated infection can spread to reproductive organs such as the
fallopian tubes, uterus and ovaries causing chronic pelvic pain or pelvic inflammatory
disease. If these conditions continue without treatment the inflammation can cause
permanent damage to these organs and lead to ectopic pregnancies or infertility (Centers
for Disease Control and Prevention).
Chlamydia infections can lead to issues of infertility but it can also cause severe
complications during pregnancy. The infection can cause preterm rupture of membranes
leading to preterm birth and some studies say it can also cause spontaneous abortions in
the first trimester (Grimshaw-Mulcahy, 2008). If the pregnancy is carried through and
the baby is born via a vaginal delivery the baby becomes at risk for conjunctivitis and
early pneumonia from the exposure of the baby to the mother’s infected cervix
(Grimshaw-Mulcahy, 2008).
Complications are rare in men but in cases where the infection spreads to the
epididymis it can cause pain, fever, and even sterility (Center for Disease Control and
Prevention).
Gonorrhea
Gonorrhea is one of the oldest sexually transmitted infections in the United States
(Schuiling & Likis, 2006). It can be transmitted by oral, anal or vaginal intercourse by
the bacteria Neisseria gonorrhoeae. Individuals who have sex with multiple partners or
unprotected intercourse are at greatest risk of transmission. Like Chlamydia, gonorrhea
infections are asymptomatic in about 80% of females, but can lead to serious
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complications such as pelvic inflammatory disease if left untreated (Schuiling & Likis,
2006). Women who experience symptoms may notice a yellow or white vaginal
discharge, burning or pain when urinating, urinary frequency, intermenstrual bleeding or
postcoital bleeding, heavier or more painful periods, cramping or pain in the lower
abdomen, fever or nausea (Forrest, 1999). Men infected with gonorrhea may experience
yellow or white drip from the penis or stained underwear, burning and frequency of
urinating, and pain and swelling in the testes (Forrest, 1999). Other signs of gonorrhea
include pain or swelling in the knees or other joints, small red blisters on the skin or other
cardiac related problems (Forrest, 1999).
Individuals with rectal gonorrhea may experience profuse purulent anal discharge,
rectal pain, blood in the stool, rectal itching, fullness, pressure or pain (Schuiling & Likis,
2006). Viral Pharyngitis, a red and swollen uvula and pustule vesicles on the soft palate
and tonsils may indicate an oral gonorrhea infection (Schuiling & Likis, 2006).
Gonorrhea is diagnosed based on history of symptoms and a positive NAAT culture
obtained from the cervix, rectum or pharynx.
Decision Point 3: Additional Diagnostic Tests:
Based on the history obtained from the patient it is suspected that Barbara has a
Chlamydia infection. To confirm this diagnosis a nucleic acid amplification test (NAAT)
is needed by obtaining an endocervical or urine sample (Schuiling & Likis, 2006). The
endocervical sample is collected by inserting a swab into the cervical os and rotating it
twice against the walls of the canal. The endocervical test is the preferred method of
collection because it provides the highest sensitivity (Schuiling & Likis, 2006).
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There are no other blood laboratory studies that are needed to diagnose
Chlamydia. If however, other differentials could not be eliminated various labs could be
obtained to help with elimination. A CBC could be drawn to check the white blood cell
count. In conditions such as PID, UTI or cystitis an elevation in white blood cells could
be expected. An abdominal CT could also be ordered to rule out appendicitis if the
history did not rule out that differential diagnosis. A NAAT endocervical sample for
gonorrhea and Chlamydia should be obtained to confirm a diagnosis.
Decision Point 4: Initial Management:
The presumed diagnosis of Chlamydia is based on Barbara’s symptoms of
intermenstrual bleeding, yellowish colored discharge, mild lower abdominal pain, and
burning with urination. Barbara’s physical exam revealed a soft, non-tender, nondistended abdomen with no rebound tenderness. Liver and spleen were not palpable.
Barbara’s pelvic exam revealed no inguinal adenopathy. No lesions or masses on external
genitalia. Mucopurulent discharge was noted in the vaginal vault. The cervix was pink
without contact bleeding. The uterus was midline, smooth and not enlarged. No adenexal
tenderness or abdominal pains were noted during the pelvic exam. These physical
findings as well as the preliminary labs help to eliminate various differential diagnoses.
The general management for Chlamydia is as follows:
Recommended Regimens for non-pregnant individuals:
 Azithromycin 1 gram orally in a single dose OR
 Doxycycline 100 mg orally BID X 7 days
Alternate Regimens for non-pregnant individuals:
> Erythromycin base 500 mg orally QID X 7 days OR
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> Erythromycin ethylsuccinate 800 mg orally QID X 7 days OR
> Ofloxacin 300 mg orally BID X 7 days OR
> Levofloxacin 500 mg orally daily X 7 days
Recommended Regimens for pregnant females:
 Azithromycin 1 g PO X 1 OR
 Amoxicillin 500 mg PO TID X 7 days
Alternate Regimens for pregnant females:
 Erythromycin base 500 mg PO QID X 7 days OR
 Erythromycin base 250 mg PO QID X 14 days OR
 Erythromycin ethylsuccinate 800 mg PO QID X 7 days OR
 Erythromycin ethylsuccinate 400 mg PO QID X 14 days
Two considerations to take when prescribing the treatment for a Chlamydia infection
is compliance and cost. If you fear compliance will be difficult for you patient it may be
easier and more beneficial to choose the singe dose Azithromycin. Azithromycin can
however be costly so a cheaper drug may need to also be considered (Likis and Schuiling,
2006).
If the patient is pregnant it is recommended that a test is repeated four weeks after
treatment to check for a cure (Grimshaw-Mulcahy, 2008). All other individuals should
be retested for a cure 3 to 4 months after initial treatment due to the high prevalence of
repeat infections as well as the risk of complications increase with repeated infections
(Schuiling & Likis, 2006).
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Barbara is told to continue with her oral contraceptives. She is encouraged to use
condoms in addition to her oral contraceptives to prevent against STI’s. Barbara is told
that if either her gonorrhea or Chlamydia results come back positive she will be notified.
Decision Point 5: Final Diagnosis and Management:
The presumptive diagnosis of Chlamydia is confirmed with the NAAT
endocervical sample result that came back positive for Chlamydia and negative for
gonorrhea. Barbara was notified of the confirmed diagnosis and given a prescription for
Azithromycin 1 gram orally once. She is instructed to abstain from sexual intercourse for
7 days. She is also instructed to have all sexual partners in the last 60 days referred for
testing and treatment (Kirkland, 2006).
Two weeks after treatment Barbara reports that all her pervious symptoms are
gone and she is feeling fine. She and her husband plan to start trying to have another
child in the next 6 months. Barbara is instructed to return if symptoms return and in 3-4
months for a repeat screening due to the high risk of re-infection and her desire to
conceive another child. She is given the following instructions regarding the
transmission of sexually transmitted infections.
> Male condoms are encouraged for all sexually active individuals not in a
monogamous relationship.
> Chlamydia infections pose possible complications during pregnancy if
untreated.
> Any genital symptoms such as an unusual sore, discharge with odor, burning
during urination, or bleeding between menstrual cycles could indicate a sexually
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transmitted infection and treatment should be initiated to reduce complications such as
PID or infertility
> Some patients have sexually transmitted infections without any symptoms, so it
is important to have routine screenings for sexually transmitted infections
> Annual STI screenings for sexually active women under the age of 25 is
recommended
Figure 1 shows a case specific decision making algorithm for diagnosing a
Chlamydia infection. Figure 2 provides a list of useful resources for patients and
healthcare providers regarding sexually transmitted infections
Case Study Summary:
In Barbara’s case she had complained of intermenstrual bleeding for two months
while on oral contraceptives. She had additional symptoms of yellowish colored
discharge and mild lower abdominal pain with a slight burning during urination. The
initial differential diagnoses included Gonorrhea, Trichomoniasis, Pelvic inflammatory
disease, Cystitis, Urinary tract infection and Chlamydia. The history, initial lab work and
physical exam eliminated all of the differential diagnoses except Gonorrhea and
Chlamydia. The NAAT endocervical sample testing for Gonorrhea and Chlamydia
confirmed the diagnosis of Chlamydia.
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Figure 1. Chlamydia Differential Decision Tree Algorithm
Intermenstrual Bleeding, Mild Abdominal Pain, Burning with urination, yellow mucopurulent discharge
Urine HCG
Positive = pregnancy
Negative = Not pregnant
Wet Mount Prep
Normal transparent, clear epithelial cells,
Positive Leukocytes and flagellate protozoan
with lactobacilli (normal)
(Trichomoniasis)
Urine Dip
Negative – protein, glucose, nitrates & leukocytes
Positive nitrates & leukocytes
(No UTI)
(Probable UTI)
Pelvic Exam
Rebound Tenderness
Positive Cervical Motion Tenderness
(Appendicitis)
(PID)
NAAT Endocervical Sample
For Gonorrhea and Chlamydia
Positive Chlamydia
(Chlamydia)
Positive Gonorrhea
(Gonorrhea)
Chlamydia
Figure 2. Resources
STD hotline 1-800-227-8922
www.plannedparenthood.org
Division of STD Prevention (DSTDP)
Centers for Disease Control and Prevention
www.cdc.gov/std
CDC-INFO Contact Center
1-800-CDC-INFO (1-800-232-4636)
Email: [email protected]
CDC National Prevention Information Network (NPIN)
1-800-458-5231
E-mail: [email protected]
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References
Centers for disease control and prevention. (n.d.). Chlamydia – CDC Fact Sheet.
Retrieved November 4, 2008, from
http://www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm
Flannigan, J. (2006, June 21). Chlamydia: the nurse’s role in diagnosis, treatment
and health promotion. Nursing Standard (Royal College Of Nursing
(Great Britain): 1987, 20(41), 59.
Forrest, K. (1999). Gonorrhea; Sexually transmitted disease [Brochure]. Santa
Cruz, CA.
Grimshaw-Mulcahy, L. (2008, April). Now I know my STDs Part II: Bacterial
and protozoal. The Journal for Nurse Practitioners. (2), 271-281.
Kirkland, L. (2006, December). New developments in the management of STDs.
The Nurse Practitioner, 31(12), 12.
Lloyd, T., Malin, G., Pugsley, H., Garcea, A., Garcea, G., Dennision, A., et al.
(2006, February). Women presenting with lower abdominal pain: A
missed opportunity for chlamydia screening?. Surgeon, 4(1), 15-19.
Madhogaria, S., Duru, C., Hart, J., Curran, B., & Jungmann, E. (2006, February).
Prevalence of Chlamydia trachomatis in sexual contacts of gonorrhea.
International Journal Of STD & AIDS, 17(2), 130-132.
Miller, K. (2006, April 15). Diagnosis and treatment of Chlamydia trachomatis
infection. American Family Physician, 73(8), 1411-1416.
Schuiling, K. & Likis, F. (2006). Women’s Gynecologic Health. Sudbury,
Massachusetts: Jones and Bartlett.
Chlamydia
Waugh, M. (2007, September). Sexually transmitted infections-microbial
infections, 2007 update. Skinmed, 6(5), 242-244.
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