Review New Case: Patient John is a
Review New Case: Patient John is a 20-year-old male. Chief Complaint: presenting with c/o “funny feeling when I pee”. History of Present Illness: having a funny feeling when urinating for about 7-8 days. Describes it as a “tingling or maybe burning” and states sometimes “notices an extra drip after finishing peeing”. He is sexually active and does not use protection “because his girlfriend is on the pill”. Denies exposure to STIs – but states “he has never been tested”. Has a history of two female partners in the last year. Most recent sexual activity was yesterday with his current girlfriend of 4 weeks. Past Medical History: Acne as an adolescent. No current treatment for the last year. Family History: Non-contributory Social History: Non/never-smoker; Drinks socially with friends on the weekend. Denies recreational drug use Full-time nursing student with part-time job as a waiter. Current Medications: none Allergies: Penicillin, Sulfa (rash) Vital signs: T: 98.5 P: 68 R: 12 BP: 110/72 O2Sat: 98% Ht: 5’11” Wt: 186 lbs Pertinent physical exam findings: Neck: no lymphadenopathy Cardiac: regular rate & rhythm, no murmurs, clicks, gallops, rubs Respiratory: lungs clear bilaterally Abdomen: soft; positive bowel sounds; no tenderness or organomegaly noted. Genitourinary: no masses; small amount of clear mucoid discharge from urethra; no lesions; 1 cm round, mobile, non-tender right inguinal lymph node. Point of Care Testing Completed (on-site): bUrine: + Leukocyte esterase; + GC/CHL gonorrhea/chlamydia) Complete the following questions and post to Discussion Board on Blackboard Module 5: What are the patient’s most significant key presenting features & risk factors? What are your top three (3) Differential Diagnoses and why? What additional diagnostic or imaging testing should be ordered and why? What is the patient’s most likely diagnosis? How is the patient’s condition typically treated?
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