Posted: March 28th, 2023

JM a 26-year-old Hispanic (the best nursing writing service, a studybay for your papers) male presents with complaints of dysuria

Patient Information:
JM, a 26-year-old Hispanic (the best nursing writing service, a studybay for your papers) male presents with complaints of dysuria and frequency.

S.
CC (chief complaint): Dysuria and frequency.
HPI: JM reports a three-day history of painful urination accompanied by frequent trips to the bathroom. He describes the pain as a burning sensation and rates it as a 7/10. JM reports no fever or chills. He denies any history of sexually transmitted infections. He reports that he is sexually active with one partner and they use condoms regularly. He denies any recent travel or new sexual partners. He has no history of kidney stones or bladder infections. He denies any abdominal or back pain, nausea, or vomiting. He denies any penile discharge or testicular pain.
Current Medications: None.
Allergies: No known drug allergies or reactions to changes in weather such as cold or heat, dust, or pollen.
PMHx: JM reports no significant medical history.
Soc & Substance Hx: JM works as a mechanic and denies any tobacco, alcohol, or drug use.
Fam Hx: No significant family history of genitourinary issues.
Surgical Hx: No prior surgeries.
Mental Hx: No significant psychiatric history.
Violence Hx: No history of sexual or physical violence.
Reproductive Hx: JM reports being sexually active with one partner and using condoms regularly.
ROS:
GENERAL: No unexpected weight loss or gain, fatigue, or chills.
HEENT: Eyes: No visual complications or yellow sclerae. Ears, Nose, Throat: No hearing difficulties, sneezing, nasal congestion, or sore throat.
SKIN: No skin rashes, lesions, or itching.
CARDIOVASCULAR: No chest pressure, palpitations, or chest discomfort.
RESPIRATORY: No cough, sputum, or shortness of breath.
GASTROINTESTINAL: No vomiting, diarrhea, nausea, or abdominal pain.
GENITOURINARY: Dysuria and frequency. No pain or burning sensation during ejaculation.
NEUROLOGICAL: No headache, numbness, dizziness, or inappropriate control of the bladder.
MUSCULOSKELETAL: No joint pain or muscle weakness.
HEMATOLOGIC: No bleeding, anemia, or bruising.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: No significant psychiatric history.
ENDOCRINOLOGIC: No history of cold and heat intolerance or polyuria.
REPRODUCTIVE: JM reports being sexually active with one partner and using condoms regularly.

O.
Vital signs: BP 120/70, HR 80, RR 16, Temp 98.6°F, O2 Saturation 99% on room air.
Physical exam:
Abdomen: Soft, non-tender, non-distended.
Genital: Normal male genitalia, no lesions or discharge.
Rectal exam: Normal tone, no tenderness, no masses, no hematuria on guaiac.

A.
Differential Diagnosis:

Urinary tract infection
Urethritis
Prostatitis
Gonorrhea
Chlamydia
P.
Plan:

Urinalysis and culture to rule out UTI.
Gonorrhea and chlamydia testing.
Start empiric treatment with antibiotics for suspected UTI.
Follow up in 1 week for test results and symptom resolution.
Education on safe sex practices and use of condoms.
References:
Kwon, J. Y., Kim, J. M., Moon, H. S., & Chung, J. H. (2019). Acupuncture for chronic low back pain: A multicenter, randomized, patient-assessor blinded, sham-controlled clinical trial. Spine, 44(9), 592-601.
Akuthota, V., Ferreiro, A., & Moore, T. (2018). Core stability exercise principles. Current sports medicine reports, 17(5), 179-184.
Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., … & Dana, T. (2021). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 174(7), 999-1017.

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