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Posted: April 20th, 2022
Week 4: Genitourinary Clinical Case
Week 4: Genitourinary Clinical Case
© 2016 South University
Week 4: Genitourinary Clinical Case 2
Patient Setting:
28-year-old female presentsto the clinic with a 2 day history of frequency, burning and pain upon
urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptomssimilarto those of previous urinary tractinfections(UTIs) which started
approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown fouls
smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history ofmultiplemale sexual partners; currently lives with newboyfriend and 3
children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regularrate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
Page 2 of 3
Advanced Nursing Practice I
©2016 South University
Week 4: Genitourinary Clinical Case 3
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10-
15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture:Gramnegative diplococci,Neisseria gonorrhoeae,sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation,Wet preparation and VDRL negative
Page 3 of 3
Advanced Nursing Practice I
©2016 South University
——————
Week 4: Clinical Case in Genitourinary Medicine
South University, 2016
Genitourinary Clinical Case 2 (Week 4)
Setting for the Patient:
A 28-year-old female arrives at the clinic with a two-day history of frequency, burning, and pain.
Over the last week, I’ve had more urination, lower abdominal pain, and vaginal discharge.
HPI
Complaints of urinary symptoms similar to previous urinary tract infections (UTIs) that began
about 2 days ago; also experiencing severe lower abdominal pain and noticing brown fouls
smelling discharge as a result of unprotected intercourse with her ex-boyfriend
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history ofmultiplemale sexual partners; currently lives with newboyfriend and 3
children.
Social: Denies smoking, alcohol and drug use
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