Week 4 (your nursing study bay): Genitourinary Clinical Case

Week four: Genitourinary Clinical Case
© 2016 South College
Week four: Genitourinary Clinical Case 2
Affected person Setting:
28-year-old feminine presentsto the clinic with a 2 day historical past of frequency, burning and ache upon
urination; elevated decrease stomach ache and vaginal discharge over the previous week.
HPI
Complains of urinary symptomssimilarto these of earlier urinary tractinfections(UTIs) which began
roughly 2 days in the past; additionally experiencing extreme decrease stomach ache and famous brown fouls
smelling discharge after having unprotected intercourse together with her former boyfriend.
PMH
Recurrent UTIs (three this yr); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Previous Surgical Historical past
Tubal ligation 2 years in the past.
Household/Social Historical past
Household: Single; historical past ofmultiplemale sexual companions; at the moment lives with newboyfriend and three
youngsters.
Social: Denies smoking, alcohol and drug use.
Remedy Historical past
None
Allergy: Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Final pap 6 months in the past, Denies breast discharge. Optimistic for Urine trying darkish.
Bodily examination
BP 100/80,
HR 80,
RR 16,
T 99.7 F,
Wt 120,
Ht 5’ Zero”
Gen: Feminine in reasonable misery.
HEENT: WNL.
Cardio: Regularrate and rhythm regular S1 and S2.
Chest: WNL.
Abd: smooth, tender, elevated suprapubic tenderness.
GU: Cervical movement tenderness, adnexal tenderness, foul smelling vaginal drainage.
Rectal: WNL.
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©2016 South College
Week four: Genitourinary Clinical Case three
EXT: WNL.
NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos eight%, EOS 2%
UA: Starw coloured. Sp gr 1.015, Ph eight.Zero, Protein neg, Glucose neg, Ketones neg, Micro organism – many, Lkcs 10-
15, RBC Zero-1
Urine gram stain – Gram adverse rods
Vaginal discharge tradition:Gramnegative diplococci,Neisseria gonorrhoeae,sensitivities pending
Optimistic monoclonal AB for Chlamydia, KOH preparation,Moist preparation and VDRL adverse
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Superior Nursing Follow I
©2016 South College

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Week four: Clinical Case in Genitourinary Drugs
South College, 2016

Genitourinary Clinical Case 2 (Week four)

Setting for the Affected person:

A 28-year-old feminine arrives on the clinic with a two-day historical past of frequency, burning, and ache.

Over the past week, I’ve had extra urination, decrease stomach ache, and vaginal discharge.

HPI

Complaints of urinary signs just like earlier urinary tract infections (UTIs) that started

about 2 days in the past; additionally experiencing extreme decrease stomach ache and noticing brown fouls

smelling discharge on account of unprotected intercourse together with her ex-boyfriend

PMH

Recurrent UTIs (three this yr); gonorrhea X2, chlamydia X 1; Gravida IV Para III

Previous Surgical Historical past

Tubal ligation 2 years in the past.

Household/Social Historical past

Household: Single; historical past ofmultiplemale sexual companions; at the moment lives with newboyfriend and three

youngsters.

Social: Denies smoking, alcohol and drug use