Urethral Discharge

HISTORY:

Urethral discharge for ‍ ‍hoursdays

Type: ‍clearwhiteyellowgreen, ‍thinthickcreamymilkywatery

‍dysuria

‍frequency

‍genital rash

‍genital itching

‍swelling

‍abdominal pain

‍testicular pain

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍nausea

‍vomiting

‍fatigue



Sexually active: ‍yesno

Condom use: ‍alwayssometimesnever

Number of partners in the last year: ‍123 ‍

Last STI screening: ‍





EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal



ASSESSMENT:

‍Urethritis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- STI screening for chlamydia and gonorrhea

- Urinalysis

- Urine culture

- Blood work: ‍HIV, ‍syphilis, ‍hepatitis B, ‍hepatitis C

- ‍Antibiotics

- Sexual partners treatment

- Abstinence until treatment completed and symptoms resolved

- Condom use

- Proper hygiene

- Referral to urologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms do not improve or if develops fever or abdominal pai