Genitourinary Clinical Assignment
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. Genitourinary Clinical Assignment Help
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 Genitourinary Clinical Assignment Help
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
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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. Genitourinary Clinical Assignment Help
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
Page 2 of 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: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending
Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL
Genitourinary Clinical Assignment Help
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