Clinical Vignette XV

• Which of the following is the most appropriate next step in management of this patient

A 22 year-old male is evaluated in the Medtigo Medical Clinic for a 3-day history of worsening dysuria, erythema of urethral meatus with itching, and mucopurulent urethral discharge. He denies any associated fever, testicular pain or swelling, rectal pain or discharge, joint pain, or skin rashes. He reports no prior history of experiencing similar signs or symptoms. He also reports no history of sexually transmitted infections. Upon further questioning, he admits going on a 4-day luxury cruise to the Bahamas with some college friends about two weeks ago to celebrate their upcoming college graduation. While on the cruise, he admits to having unprotected sexual intercourse on three separate occasions with three different female partners. The patient states, “I didn’t know who the women were. I was just having some fun and really wasn’t thinking. I’m usually really careful and use protection but I’m not quite sure what happened while I was on that cruise. It was probably all the drinking we did.” He drinks alcohol socially on the weekends and on special occasions, does not smoke or chew tobacco products, and denies the use of recreational drugs. He has never been tested for HIV or any other sexually transmitted infections. He currently takes no medications and has no known allergies. The rest of his medical history, social history, and family history is non-contributory. 

On physical examination, vital signs are normal. He is 5’10” (177.8 cm), 170 lbs (77.1 kg), with a body mass index of 24.4 kg/m². Erythema of the urethral meatus is visualized. Slight milking of the urethra reveals mucopurulent discharge from the urethral meatus. There are no ulcerated lesions, rashes, or other grossly abnormal findings in the genital and perineal regions. The remainder of the physical examination is unremarkable.

Based on the patient’s history of present illness, clinical exam findings, and Gram stain analysis, which of the following bacterial pathogens is the most likely cause of this patient’s signs and symptoms?

• The gram stain analysis of the urethral discharge sample using microscopy reveals the following:

• Which of the following is the most appropriate next step in management of this patient?

• After obtaining a urethral discharge sample for nucleic acid amplification testing, which of the following is the most appropriate next step in management of this patient?

• Two days later, the results of the patient’s nucleic acid amplication tests (NAAT) are available and confirm the presence of Neisseria gonorrhoeae and Chlamydia trachomatis in the patient sample. Which of the following is the most appropriate next step in management of this patient?