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April 3, 2023

Suzanne is accompanied to the clinic by her boyfriend. Suzanne is 5 feet 6 inches tall, 117 pounds. BP 132/76 mmHg, T 100.2 F. (37.9 C.), P 98 beats/minutes, RR 18 breaths/minutes. Medical h

24-year-old female who comes to the community clinic with complaints of increased vaginal discharge, pain with intercourse, lower abdominal pain, and urinary frequency. Suzanne reports her symptoms started over a week ago. Suzanne is accompanied to the clinic by her boyfriend. Suzanne is 5 feet 6 inches tall, 117 pounds. BP 132/76 mmHg, T 100.2 F. (37.9 C.), P 98 beats/minutes, RR 18 breaths/minutes. Medical history: Suzanne’s medical history is significant for one elective first trimester pregnancy terminations and two full term spontaneous vaginal deliveries. Suzanne’s boyfriend states she gave the two children up for adoption. Medications: NKA. Surgical history: Tonsillectomy at age 5 Social history: Suzanne is new to the area and has not established a primary care provider.
Provider exam: Alert and orientated to person, place and time, Lungs clear, heart rate 98 without murmur. Lower abdominal tenderness, + and active bowel sound in all 4 quadrants. Vaginal exam + malodorous, thick greenish creamy discharge. Cervix friable with erosion. + Cervical motional tenderness. No lesions present on perineum or rectum. Legs without edema and WNL.

Dx: Probable Gonorrhea

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