NR 603 Week 5 Part 1 Assignment: Peer Response

24-year-old Caucasian male.

Subjective:

CC: Dysuria and penile discharge

HPI: K.G a 24-year-old Caucasian male who presents to the clinic with a chief complaint of Dysuria and penile discharge, which he noticed for the last two days. Reports having unprotected sex in the previous two weeks and also inconsistent in the use of condoms in the past month. He has a cloudy discharge from the penis, pain, and burning sensation on urination. Pain is 3/10 around the testicles that is continuous, has not tried any treatments but has abstained from any sexual relations in the last three days.

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Current medications: None

Allergies: None

Past Medical History: Seasonal allergies

Past Surgical History: None

Lifestyle: Lives with a younger brother. Mother, father, and sister live in another city. Drinks alcohol occasionally, denies tobacco/illicit drugs. Works 32 hours as a project manager in a Higher Education institution, goes to school part-time pursuing a Master’s degree, and works out 2-3x/week. Reports having multiple sexual partners.

Family Hx: Mother and father are healthy and live an active lifestyle w/ no medical history. Maternal grandmother has DM2, controlled with meds and insulin; maternal grandfather deceased at 90 from prostate cancer, paternal grandmother died at 75 from CAD, history of DM2 and HTN, paternal grandfather deceased at 87 from CAD and had prostate cancer. Denies any psychiatric /mental illness/disorders. NR 603 Week 5 Part 1 Assignment: Peer Response

Vaccines/Immunizations Hx: Up to date, Flu vaccination Jan 2020

ROS:

CONSTITUTIONAL: Denies N/V/D, fever/chills or fatigue

HEENT: Denies any headaches, tinnitus, blurry vision, or discharge and sore throat.

CARDIOVASCULAR: Denies chest pain/pressure, palpitations, cyanosis or edema

RESPIRATORY: Denies any coughing, wheezing, sob, and difficulty in breathing

NEUROLOGIC: Denies any tingling, numbness of cheeks and mouth, any history of seizures, tremors, or vertigo.

ENDOCRINOLOGIC: Denies a history of DM, thyroid, tolerance to heat/cold, or changes in weight.

GASTROINTESTINAL: Denies any heartburn, indigestion, N/V, change in bowel pattern, or any abdominal pain.

GENITOURINARY: Denies frequency, urgency, or incontinence. Denies any pelvic pain. Reports Dysuria and cloudy yellow discharge. Reports pain with sex but has abstained for the last three days, denies any itching

SKIN: Denies any changes in skin or nails.

MUSCULOSKELETAL: Denies any joint pain/stiffness/swelling/cramping/tingling/numbness of extremities. Denies any muscle weakness or any abnormality in gait. Denies any limitation in ROM.

HEMATOLOGIC/LYMPHATIC: Denies any history of anemia, bruising, bleeding, or history of blood transfusion.

PSCYHIATRIC: Denies any history of anxiety, depression, changes in mood

ALLERGIC/IMMUNOLOGIC: Denies any reaction to medications, food, or environmental exposures, denies any history of asthma. NR 603 Week 5 Part 1 Assignment: Peer Response

Objective:

Physical Exam

VITALS: BP 110/72, heart rate: 80, respirations: 18, SPO2: 100% RA, height: 5’8, weight: 180 lbs., BMI: 27.4, pain 3/10 testicles

CONSTITUTIONAL: Well-groomed and appropriate, concerned, and nervous but not in any acute distress.

HEENT:

Head: Normocephalic, head position midline, normal hair distribution on scalp

Eyes: PERRLA,

Ears: TM pearly gray, pinna non-tender

Nose: Nasal septum is midline, and Turbinates’ are moist and free of lesions.

Neck: NonTender, Full ROM, trachea midline.

Throat: Oropharynx moist without exudate, +2 tonsils

Mouth: Oral mucosa pink and moist

CARDIOVASCULAR: S1 & S2 noted, no murmurs, no edema noted.

RESPIRATORY: Respiratory rate is normal, unlabored breathing with normal respiratory effort, lungs CTA bilaterally.

NEUROLOGIC: A+Ox4

GENITOURINARY: Penile discharge, swollen testicles, no lesions

ABDOMEN: +BS x4 Quadrants, non-tender/ none distended, no palpable masses, no guarding,

SKIN: Skin is pink, warm and moist, normal turgor w/ no open wounds.

MUSCULOSKELETAL: +ROM, muscle strength 5/5 bilateral and equal

HEMATOLOGIC/LYMPHATIC: No swollen lymph nodes, No bruising/bleeding/swelling.

PSYCHIATRIC: No depression/anxiety/mood swings.

ALLERGIES/IMMUNOLOGIC: NKA

Associated risk factors /demographics that contribute to the cc and differentials:

Based on the CAGE assessment; the patient has no comorbidities at this time that would increase his risk, his diagnosis can affect persons < 25 years and persons younger than 20 are at a higher prevalence, is common in females than in men and African American race have a higher prevalence and lower socioeconomic groups. Multiple sexual partners and unprotected sex and history of STDs increases the risk (Am Fam Physician, 2015).

Risk factors: Pt’s risk factors that contribute to his CC are; Age- 20-24 years old has the highest incidence, unprotected sex, multiple sexual partners, K.G has no past history of STDs. NR 603 Week 5 Part 1 Assignment: Peer Response

Three differential diagnoses represented by the cc based on their pertinent

Chlamydia
Gonorrhea
Urethritis

Chlamydia

Pertinent positives: Dysuria, penile discharge, testicle pain, painful ejaculation

Pertinent negatives: No rectal pain, no prostate pain

Gonorrhea

Pertinent positives: urethral discharge, Dysuria, painful ejaculation, testicular pain

Pertinent negatives: No blood in the urine, No frequency, No penile edema

Urethritis

Pertinent positives: Pain on ejaculation, Dysuria, Testicular pain

Pertinent negatives: Denies any fever, chills or malaise, No frequency or urgency, No back pain

Discussing the 3 DD’s how they differ (occurrence/ patho/ presentation)

Occurrence:

Chlamydia and Gonorrhea are both the most common sexually transmitted infections (STIs) affecting people aged 15-24 years old. Chlamydia is the most common bacterial sexually transmitted disease, with prevalence estimated over 140 million infected individuals. In the U.S., the highest chlamydial infection rates are seen in young people with the highest incidence of those aged 15–19 years followed by those aged 20–24 years. The prevalence of chlamydia is substantially higher in females than in males (Center for disease control (CDC), 2017). Gonorrhea is the second most common sexually transmitted disease (STD), after chlamydia. In 2016, gonorrhea rates were the highest in adolescent and young adult women. In males, the highest rate of Gonorrhea is seen in persons aged 20–24 years, with a high infection rate in Blacks and the South in the United States (CDC, 2017). Urethritis is more commonly diagnosed in males. Risk factors include young age, unprotected sexual intercourse, and multiple sexual partners (Young, 2020). NR 603 Week 5 Part 1 Assignment: Peer Response

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Pathophysiology:

Chlamydia and Gonorrhea are both sexually transmitted infections (STIs) caused by bacteria, and urethritis is the inflammation of the urethra, which mostly occurs in the presence of the STIs.

Chlamydia is caused by gram-negative bacterium Chlamydia trachomatis, which can cause cervicitis, urethritis, pelvic inflammatory disease in women and urethritis, and in men it could cause epididymitis, prostatitis, and proctitis (Mohseni, 2019).

Gonorrhea is caused by a gram-negative bacterium Neisseria gonorrhoeae , which primarily colonizes the urogenital tract after sexual contact with an infected individual. For non-complicated Gonorrhea, there is a massive recruitment of neutrophils to the site of infection, leading to the formation of a pustular discharge (Hill, Masters, & Wachter, 2016).

Urethritis is inflammation of the urethra and is a lower urinary tract infection. Neisseria gonorrhea and Chlamydia trachomatis are the most common causative organisms. If chlamydia trachomatis is the cause, then the incubation period is usually 7-14 days; if the causative agent is Neisseria Gonorrhea, the incubation period is 2-5 days (Young, 2020).

Urethritis is either caused by chlamydia trachomatis or Gonorrhea therefore the symptoms are based on the causative agent.

Presentation of clinical s/sx:

Chlamydia, Gonorrhea, and urethritis when symptomatic will present with Dysuria, penile or vaginal discharge, and testicular pain in men.

Most people with chlamydia have no symptoms, but when symptomatic men will present with penile discharge, burning or pain on urination, and testicular pain. Women will present with abnormal vaginal discharge and pain or burning sensation on urination (CDC, 2015). Men with Gonorrhea may be asymptomatic, but when symptomatic, they usually present with pain or burning sensation when urinating, white, yellow, or green penile discharge and swollen testicles. Women may be asymptomatic or present with mild symptoms, which include Vaginal discharge, bleeding in between periods, and pain or burning sensation when urinating (CDC, 2015).

Urethritis is commonly asymptomatic; if symptomatic, the symptoms vary based on the causative organism. Symptoms of urethritis may include Dysuria, pruritus, burning, and discharge at the urethral meatus. Frank purulent discharge suggests Gonorrhea as the causative organism. Dysuria alone is common among chlamydia. Women may also present with frequency and urgency (Young, 2020).

All these three conditions have an overlapping clinical presentation and could be mistaken for another; therefore, testing is required to identify causative organisms so that the right treatment can be initiated.

Relevant testing required to diagnose/evaluate the severity of the three differential diagnoses.

A complete blood count is necessary if PID is suspected in female patients. Another consideration for testing is HIV, Gonorrhea, and syphilis which is recommended based on symptoms.

Chlamydia and Gonorrhea can be diagnosed by testing first-catch urine or collecting swab specimens from the endocervix or vagina for women and urethral swab specimens for men. Nucleic acid amplification test (NAAT) is the recommended method of testing for Gonorrhea and chlamydia (Mohseni, 2019). Also, according to the Centers for Disease Control and Prevention (CDC), it is recommended to use a supplementary PCR targeting a different gene for confirming the results of a screening test on urogenital specimens, especially for Gonorrhea.

Urethritis is mostly a clinical diagnosis based on history and physical examination. The diagnostic lab test shows >2 WBC per oil immersion field from gram stain of a urethral swab, positive leukocyte esterase, and presence of >10 WBCs per high-power area of the first-void urine (Young, 2020).

Review of relevant National Guidelines related to the dx and diagnostic testing for these diagnoses:

According to the CDC guidelines, NAATs are the most sensitive tests for these specimens and, therefore, are recommended for detecting chlamydia and Gonorrhea (CDC, 2015). The gold standard for the diagnosis of urogenital chlamydia infections is nucleic acid amplification testing (NAAT). This test is run on either the vaginal swabs for women or first-catch urine for men (Mohseni, 2019). NR 603 Week 5 Part 1 Assignment: Peer Response

NR 603 Week 5 Part 1 Assignment: Peer Response