Posted: August 11th, 2024

J.L. is a 17 yo junior in high school who presents to her pediatrician’s office

Patient Case Study
Patient’s Chief Complaints
“I probably have done something that I shouldn’t have on prom night and now it hurts when I go to the bathroom.”
HPI
J.L. is a 17 yo junior in high school who presents to her pediatrician’s office. She has been in reasonably good health for the past 17 years but has recently developed urinary tract manifestations—urgency to urinate, more frequent urination, and increasingly severe urethral burning during urination that has persisted for three days. She awoke from sleep with urgency last night and noticed an abnormal discharge from her vagina. She describes the discharge as “yellow and kind of thick.” She reported this to her mother who kept her out of school today and immediately
made a doctor’s appointment. She also reports mild anal itching, but denies chills, fever, nausea, vomiting, and abdominal pain. When questioned further, she reported that she “had sex for the very first time with my prom date two weeks ago.” They did not use a condom, but she has been taking the pill for six months. She denies oral and anal intercourse. Her LMP occurred four days ago. She denies any recent travel other than to local volleyball games on the school bus.
PMH
• (–) previous history of urinary or female reproductive tract infections
• (–) previous pregnancies
• Asthma
11 years
• Immunizations are up to date and patient receives annual physical examinations and routine follow-up care for asthma
FH
• Father died last year from sudden cardiac death at age 45
• Mother has a heart murmur
• Younger brother, age 15, is in good physical health Older brother, age 19, is having “muscle problems in his hands and arms, but the doctors
don’t know yet what is causing them”
• Maternal grandmother has “high blood pressure”
SH
J.L. is very popular at school and is well liked by her teachers and classmates. She has dated a few boys from school, but claims not to have been sexually active before prom night. She comes from an upper socioeconomic background. She does not drink alcohol, smoke, or use any recreational drugs. She claims that it is “very uncool” with her friends to engage in any activities like that. She is on the varsity volleyball team and practices most days after school.
Her home life has been difficult during the past 10 months due to the death of her father, with whom she was very close. J.L. claims that, for the most part, she has a very caring and close family.
Meds
• Ethinyl estradiol 35 µg with norethindrone 0.5 mg (7 tablets) ethinyl estradiol 35 µg with norethindrone 0.75 mg (7 tablets) ethinyl estradiol 35 µg with norethindrone 1 mg
(7 tablets)
• Albuterol 90 µg MDI 2 puffs PRN
• Beclomethasone 42 µg MDI 2 puffs TID
• Salmeterol 21 µg 2 puffs Q 12 h
• Albuterol 2.5 mg with ipratropium bromide 0.5 mg per 3 mL for nebulization PRN
All
NKDA
Patient Case Question 1. Why is the patient taking ethinyl estradiol and norethindrone?
Patient Case Question 2. Why is the patient taking albuterol and beclomethasone?
Patient Case Question 3. Briefly describe the mechanisms of drug action for albuterol
and beclomethasone that make them uniquely different but important.
ROS
• () increased frequency of urination and urgent urination with mild incontinence
• (–) rectal discharge and bleeding
• (–) rectal pain, tenesmus, and constipation
• (–) rash and other skin manifestations
• (–) joint/tendon pain and swelling
• (–) recent onset headache, neck pain, and stiffness
• (–) chest pain, cough, SOB, and palpitations
• (–) sore throat and dysphagia
PE and Lab Tests
Gen
• WDWN young, white female in NAD
• Pleasant and trim but appears mildly fatigued
VS
See Patient Case Table 100.1
Patient Case Table 100.1 Vital Signs
BP 114/64 mm Hg, sitting RR 16 not labored WT 114 lbs
P 120 BPM regular T 98.7°F HT 65 in
Skin
• Intact, warm, and dry with good turgor
• (–) rashes, bruises, papules, and pustules
HEENT
• PERRLA
• (–) photophobia
• EOMI
• No hemorrhages, exudates, or papilledema on funduscopic exam
• Sclerae white without icterus
• (–) conjunctival erythema, edema, and exudate
• TMs clear throughout with no drainage
• (–) erythema, swelling, and exudate within pharynx
Neck/LN
• Neck supple without masses
• (–) lymphadenopathy, JVD, bruits, and thyromegaly
Chest
• Normal breath sounds without wheezes
• Good air entry
• (–) breast lesions or discoloration
Cardiac
• RRR
• (–) murmurs and rubs
• S1 and S2 normal
• No S3 and S4
Abd
• (–) for rebound tenderness and guarding in all 4 quadrants with palpation
• Soft and non-distended
• () BS
• (–) HSM
• (–) masses and bruits
Genit/Rect
• (–) vulval erythema and edema
• Vagina with thick yellow-white discharge and mild erythema
• Cervix is friable and shows yellow-white discharge from os
• (–) masses on bimanual exam
• () cervical motion tenderness
• (–) adnexal tenderness
• (–) stool heme
• () mild anal erythema and edema
MS/Ext
• (–) adenopathy, lesions, and rashes
• (–) arthritis and tenosynovitis
• Capillary refill WNL at 2 sec
• (–) femoral bruits
• (–) CCE
• Pulses 2 throughout
• Normal ROM and muscle strength at 5/5 throughout Neuro
• A & O
3
• CNs II–XII intact
• DTRs 2 and symmetric bilaterally
• No gross motor-sensory deficits present
• (–) Babinski
Laboratory Blood Test Results
See Patient Case Table 100.2
Patient Case Table 100.2 Laboratory Blood Test Results
Na 134 meq/L Glu, fasting 98 mg/dL WBC 13.5
103/mm3
K 4.4 meq/L Mg 1.9 mg/dL • Neutros 70%
Cl 101 meq/L Phos 4.2 mg/dL • Bands 8%
HCO3 27 meq/L Hb 13.4 g/dL • Lymphs 17%
BUN 12 mg/dL Hct 43.1% • Monos 4%
Cr 1.1 mg/dL Plt 225
103/mm3 • Eos 1%
UA
• Color: dark yellow
• Appearance: slightly cloudy
• SG: 1.022
• pH 5.0
• 10 WBC/HPF
• 10 RBC/HPF
• () gram-negative diplococci
Nucleic Acid Amplification Test
• PCR of cervical swab specimen: () Neisseria gonorrhoeae and Chlamydia trachomatis
• PCR of urine specimen: () Neisseria gonorrhoeae and Chlamydia trachomatis
Patient Case Question 4. Identify the single most important risk factor in this case study.
Patient Case Question 5. Identify the two most definitive signs of gonorrhea in this
patient.
Patient Case Question 6. Provide a specific assessment/diagnosis of this patient’s
condition.
Patient Case Question 7. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal proctitis.
Patient Case Question 8. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal urethritis.
Patient Case Question 9. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal cervicitis.
Patient Case Question 10. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal pharyngitis.
Patient Case Question 11. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal conjunctivitis.
Patient Case Question 12. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal perihepatitis.
Patient Case Question 13. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal pelvic inflammatory disease.
Patient Case Question 14. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal meningitis.
Patient Case Question 15. Briefly cite the clinical evidence that supports or excludes
a diagnosis of gonococcal endocarditis.
Patient Case Question 16. Which three blood test findings are consistent with a diagnosis of gonococcal infection?
Patient Case Question 17. Briefly cite the clinical evidence that supports or excludes
a diagnosis of disseminated gonococcal infection

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Tags: Adolescent Sexual Health, Gonococcal Infection, Healthcare essays, Medical research papers, Urinary Tract Symptoms