Genitourinary Clinical Case

NSG6001-Advanced Nursing Practice I

Week 4 Assignment  

Genitourinary Clinical Case

Patient Setting:

28-year-old female presents to 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 symptoms similar to those of previous urinary tract infections (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 of multiple male sexual partners; currently lives with new boyfriend 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: Regular rate 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.

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: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative