Patient: Male 56 years old

Patient: Male 56 years old

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History and physical

Chief complaint: complaining of a white milky discharge from his penis

HPI: unprotected sex with a woman he met in Las Vegas. The discharged started 4 days ago and he is experiencing pain with urination

Past medical history:HTN and Inguinal hernia

Surgeries: none

Medications: HCTZ

Allergies: NKDA
Review of systems:

HEENT: denies any head trauma,denies any vision problems, denies any denies rhinorrhea, denies epistaxis, denies sore throat, denies any hearing issues

Respiratory: denies any cough, sputum production, SOB, wheezing

Cardiovascular: Denies any chest pain, palpitations, or edema in extremities

GI: Denies any vomiting, diarrhea, constipation, abdominal pain

GU: white milky discharge from his penis, pain with urination, denies hematuria, sexually active,

Musculoskeletal: denies any pain, swelling to joints

Skin: denies any rashes, wounds, sores,

Assessment:

Vital signs:

BP: 130/76 HR: 88 RR: 18 Temp: 98.6F SPo2: 98 Weight: 190 lbs. Height: 5’9”

HEENT head normocephalic, no abnormalities to scalp
Eyes: PERRLA, EOMI CN-intact
Ears: Right normal canals tympanic membrane clear, Left normal canal tympanic membrane clear
Nose: no deviations noted or evidence of epixatis
Throat: tongue midline, normal pharynx, normal voice,
Neck: no thyroid enlargement, no carotid bruits

Chest: normal breath rate, lungs clear in all lobes

Heart:heart rhythm regular, normal heart sounds S1and S2, no murmurs or extra sounds heard no chest rub, capillary refill less than 3 seconds, no edema present
Abdomen:soft, flat, no masses

Genitalia/rectum: white milky penile discharge , no lesions, Testes descended bilaterally, smooth, without masses and Epididymis is nontender. Right Inguinal hernia nontender, able to reduce.

Musculoskeletal: intact reflex in all extremities, stable gait,

Skin:warm, dry, no open ares, rashes,

Social Hx: nonsmoker, nondrinker, travels extensively and has never had this problem before.

Collect a gram stain

Diagnosis: Nongonococcal Urethritis, Chlamydia

Education: Safe sex practices, nutrition, exercise, refrain from sexual activity until 7 days after medication therapy is completed

Plan: Azithromycin 1g PO x 1 dose

The patient in the scenario presented with signs and symptoms of Chlamydia infection. Chlamydia is a Sexuallaly transmitted Infection that is acquired thru unprotected sexual activity. Chlamydia can cause vagina and penis discharge . Chlamydia can also cause reproductive system harm in females like PID, inability to get pregnant and ectopic pregnancy(STD Facts – Chlamydia, 2017). Patient need education on how prevent future infection, and the need to treat their partners also. The patient can be treated with antibiotics.

References:
STD Facts – Chlamydia. (2017, October 4). Retrieved from https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm