Response 1:
A 19-year old male complains of “burning sometimes, when I pee”. Is sexually active and denies using any contraceptive method.
SUBJECTIVE
CC : “ I have been feeling burning when I pee sometimes.”
HPI: 19 year old male presents for care due to burning sensation when he urinates. He is sexually active and does not use any form of contraception or protection.
Questions to as for HPI: How long has it been happening?
How many sexual partners do you have?
What is the gender of your partner/s?
PMH: Do you have a history of UTI?
Have you ever tested positive for STIs?
Do you have any chronic health conditions such as diabetes?
MEDs: NA
Are you currently taking any medication that is prescribed?
Are you currently taking any over the counter medications?
Allergies: NA
Do you have any food allergies?
Do you have any medication allergies?
FH: Does your mother suffer from chronic health conditions?
Does your father suffer from chronic health conditions?
Do your siblings suffer from any chronic health conditions?
Social Hx: Do you smoke?
Do you do any recreational drugs?
Do you drink alcohol?
Health Related Behaviors: How many sexual partners have you had in the last year?
What is the gender of your sexual partner/s?
Do you test for STI’s every 6 months or every time you change sexual partners?
Review of Systems (ROS)
Constitutional/General – Denies any recent changes to general health.
Cardiac – Denies Irregular heartbeat, chest pains, and swelling of feet or legs.
Respiratory- Denies any respiratory issues.
GI – Lower abdominal pain.
GU – Painful urination, frequent urination, urgency. Denies unusual discharge. Strong smelling urine. Denies pain in testicles. Denies hesitancy.
Dermatologic – Denies any issues with skin.
Psychiatric – Denies anxiety, suicidal and homicidal ideation.
OBJECTIVE
Vital signs : BP 122/78
Temp 100.3 F
RR: 18
HR: 80
Physical Exam
General: Pt is awake, alert and oriented to time, person, place, and situation. No acute distress. Patient appropriately dressed for event.
Skin: Skin in warm, dry and intact without rashes or lesions. No swelling noted on tip of penis. Testes normal without tenderness or swelling.
Cardiac: The external chest is normal in appearance. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity. No S3 or S4 heard.
Respiratory: The chest wall is symmetric and without deformity. No signs of trauma. No signs of respiratory distress. Lung sounds are clear in all lobes.
Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. Bowel sounds are present and normoactive in all four quadrants. No masses are noted.
Genital: External genitalia normal in appearance without lesions, swelling, masses or tenderness. Uncircumcised. Testes are normal in size without swelling noted.
Psychiatric: Appropriate mood and affect noted. Good judgement and insight. No suicidal or homicidal ideation.
ASSESSMENT
Acute Urinary Tract Infection (N39.0)- Working diagnosis
A urinary tract infection is caused by bacterial infection. It presents with painful urination, frequent urination, urgency, hesitancy, cloudy, strong smelling urine, and low grade fever (Bono & Reygaert, 2021). Therefore pertinent positives include painful urination, urgency, frequency, cloudy urine, strong smelling urine, low-grade fever while a pertinent negative includes hesitancy.
Chlamydia (A7.9) – Differential Diagnosis 1
Chlamydia is a sexually transmitted disease that is caused by the bacterium Chlamydia trachomatis. According to Mosheni et al. (2021), this infection can be asymptomatic, however, when symptoms present it can include painful urination, lower abdominal pain, unilateral testicular pain, unusual discharge and palpable swelling of the epididymis. Therefore pertinent positives include painful urination, and lower abdominal pain while pertinent negatives include unusual discharge, unilateral testicular pain, and palpable swelling of the epididymis.
Gonorrhea (A54.9) – Differential Diagnosis 2
Gonorrhea, known as Neisseria gonorrhoeae is a sexually transmitted disease caused by a bacteria. It usually presents in males as penile discharge, dysuria, testicular discomfort including inflammation/swelling of foreskin, and pain/tenderness in the testicles (Springer & Salen, 2021). Therefore pertinent positives include painful urination while pertinent negatives include penile discharge, inflammation/swelling of foreskin, pain/tenderness in the testicles.
PLAN
New tests or orders?
Perform a urine dip stick in office to check for UTI. Send urine out to lab for urinalysis as well as culture and sensitivity testing (Mayo Clinic, 2021). Order HIV (blood test), Chlamydia/Gonorrhea (urine) tests.
What discharge instructions/Education will you give the patient?
Educate patient on importance of safe sex practices. If monogamous, it is still important to use condoms to prevent unwanted pregnancies. If not monogamous, it is important to wear a condom to prevent getting STI’s. Test for STI’s every 6 months if sexually active and test before commencing having sexual relationships with a new partner.
Educate on prevention of UTIs. Inform patient that urinating before and after having intercourse allows for bacteria to be pushed out of the urethra to prevent bacterial growth and possible urinary tract infection. Stay hydrated, as hydrations helps in prevention of UTI. Educate patient on importance of cleaning foreskin often to prevent bacterial build up.
How soon should the patient come back for follow-up?
Return to clinic in 3 days for test results if dipstick does not show signs of UTI. If dipstick shows sign of UTI, return to clinic once antibiotic course has been completed if symptoms have not been resolved.
Medications: a. If patient has UTI: Bactrim 2 tabs every 12 hours X 14 days (Drekonja et al., 2021) b. If patient has chlamydia: Azithromycin 1000mg X 1 time by mouth (CDC, 2021). c. If patient has gonorrhea: Ceftriaxone 500 mg IM in single dose (CDC, 2021).
Response 2:
A 32-year old male complains of severe pain to the left flank pain for approx. 2 hours. Was playing volleyball at the beach when it occurred. Admits to drinking 5-6 cans of beer throughout the day and denies other fluid intake
SUBJECTIVE: 32yo male self-reports severe left flank pain lasting two hours while playing volleyball at the beach. Patient admits to drinking 5-6 cans of beer throughout the day and no other fluids taken.
HPI: Severe left flank pain for two hours while playing volleyball. Reports alcohol consumption of 5-6ncans of beer with no other fluid intake.
PMH: Denies past medical history or hospitalizations. States current on immunizations.
Allergies: NKDA
Medications: none
Family History: none reported
Constitutional Sx: Severe left flank pain for 2 hours with exercise.
Vitals: T 98.9, BP 120/67, HR 78, O2 100% HT 5’11 WT 160
EYES: no blurred vision, no doubled vision
HEENT: No head injury, no ears ringing, no nasal drainage or bleeding, no throat pain
Cardiovascular: No irregular heart rate, chest pain
Respiratory: no difficulty breathing
Gastrointestinal: no abdominal pain, vomiting, nausea
Genitourinary: Severe left flank pain for 2 hours
Musculoskeletal: no difficulty with rom muscle pain
Integumentary: no skin lesions or conditions
Neurological: no difficulty with functional ability
Psychiatric: no suicide risk factors, denies depression
Endocrine: no thyroid or diabetes
Hematologic/Lymphatic: no blood disorders
Allergic/immunologic: no immune disorders or allergic responses
QUESTIONS:
Has this ever happened to you before?
Do you have any symptoms of painful urination or burning urination?
Do you have frequency of urination or must get up at night to urinate?
Do you drink water? How much daily?
Have you ever had a prostate exam?
Are you sexually active?
Do you have more than one sexual partner?
Have you been tested for sexually transmitted diseases?
Have you noticed any discharge or malodors from your penis?
How much alcohol do you consume daily?
Do you consider yourself depressed?
Are you a risk for suicide?
If so do you have the means?
Do you have any mental disorders?
What do you do for work?
What is your family support system like?
Do you live alone?
Do you smoke? or Drugs?
Any health issues? Hospitalizations? Family history?
OBJECTIVE:
Physical Exam
General: Height:5”11, WT 160 lbs. VS: T 98.9, BP 120/67, HR 78, O2 100% RA, R 20
32yo male well-mannered and dressed in sports attire well groomed. Alert and oriented x3. Appears calm and slight discomfort.
Skin: Warm and dry, good turgor, no rashes or lesions, no masses, no discoloration, no lacerations, or abrasions. Nails pink and hair distribution is normal without hair loss.
HEENT: Head is normocephalic, EYES pink and moist conjunctiva, no discharge. PERRLA, EOM present bilaterally, normal visual acuity, white sclera. EARS free from discharge in bilateral canals, tympanic membranes without erythema or impaction, NOSE nares patent bilaterally, no septal deviation, no erythema no visible drainage present. SINUSES no tenderness present. THROAT: gag reflex present, tongue midline without deviation.
Neck: nontender left and right cervical lymph nodes. Normal ROM, trachea is midline, no stridor, no bruit, strong carotid pulses present.
Respiratory System: Bilateral lung sounds clear to auscultation in all fields, normal breath sounds present, no rales, rhonchi, or wheezing, no cough with deep breathing. Symmetry chest wall and expansion.
Cardiovascular System: Heart is without murmur, gallop, with normal rate and rhythm. Pulses present and regular rhythm.
Abdomen: abdomen is flat smooth and nondistended, bowel sounds present in all four quadrants, no splenomegaly, or hepatomegaly.
Genitourinary: Severe left flank pain for 2 hours. Positive CVA tenderness.
Musculoskeletal: normal ROM to upper and lower extremities, no rigidity, good muscle tone and strength and coordination.
Neurological: Intact cranial nerves II through XII.
PERTINENT POSITIVE: Urinary Tract infection- Infection or inflammation of kidney, bladder, or urethra. Etiology: E-coli or Staph are the most common causes. Women are more common than men for UTI infections due to short urethras and the proximity to the rectum (Hollier, 2021).
PERTINENT NEGATIVE: Sexually Transmitted disease: Pelvic disease caused by infections can cause urethritis in men and lead to pelvic inflammatory disease, infertility and chronic pelvic pain (Hollier, 2021).
PLAN
Lab test:
CBC, CMP, Clean Catch Urine specimen with urine Culture and Sensitivity, Wet prep, GC/Chlamydia Culture, HSV viral swab,
Treatment:
UTI- Macrobid 100 mg BID for 7 days
STD-_Chlamydia/GC treatment with azithromycin 1 gm single dose.
HSV with Acyclovir 1 gm po for 7 days then 500 mg daily.
PID- Rocephin 2 gm IM x 1 dose plus doxycycline 100 mg for 14 days
Referrals: Positive screening for depression. Recommend counseling referral to behavioral therapist.
Education: Discussed with patient education on causes of urinary tract infections. Encouraged increase water intake. Keep bladder empty and especially after intercourse. Maintain good hygiene and if uncircumcised proper hygiene of foreskin is imperative. Use condoms during sexual activity. Limit alcohol intake in social settings to 1-2 drinks and drinks plenty of water.
Follow up: I would recommend follow up in 3 weeks after taking all medications. However, if elevated fever, or worsening pain and symptoms persist a sooner follow-up is recommended. Patient will need retest for urine and STD testing.