Evaluation Of Adults Burning With Urination Discussion Paper

Evaluation Of Adults Burning With Urination Discussion Paper

Introduction

A 21-year-old male presents to the clinic with complaints of burning urine and clear penile discharge for the last three days. His sexual history shows multiple sexual partners and irregular use of condoms, and these are pitfalls for contracting STIs. This discussion will look at differential diagnoses, the most likely diagnosis, pathophysiology, and tests/imaging studies. We will also look at the management steps as well as the Patient Education, Medical/Legal Concerns, and Interprofessional Collaboration. Evaluation Of Adults Burning With Urination Discussion Paper

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Differential Diagnosis

Different conditions are identified as possible differential diagnoses, including gonococcal urethritis, non-gonococcal urethritis, chlamydia infections, herpes simplex virus, and UTI (Sadoghi et al., 2022). Consequently, with his sexual history and the symptoms displayed, STIs alone are more foreseeable.

Most Likely Diagnosis

Based on the symptoms described, the most probable diagnosis is acute, non-specific urethritis (NGU) caused by Chlamydia trachomatis. This is accompanied by a clear discharge and the patient’s admission of having multiple sexual partners and sometimes using the wrong condoms inconsistently. They include Chlamydia, which is a significant cause of urethritis and may manifest similarly to this infection (Sadoghi et al., 2022)Evaluation Of Adults Burning With Urination Discussion Paper.

Pathophysiology and Tests/Imaging Studies

Chlamydia trachomatis mainly targets the epithelial cells of the genital system, leading to inflammation and discharge. It interferes with normal cell metabolism and elicits an immune response that produces the common signs of urethritis. Screening should involve NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae from the urine and urethral swab. HIV, syphilis, and hepatitis – from the patient’s sexual behavior and practices (Sadoghi et al., 2022)Evaluation Of Adults Burning With Urination Discussion Paper. No first-line imaging is required, although specific complications usually require some form of imaging.

Management Steps

Empirical treatment entails the administration of antibiotics without knowing the specific organism, which in the case of Chlamydia is azithromycin or doxycycline, while for gonorrhea is ceftriaxone. People with the disease must notify their partners and seek treatment to prevent reinfection and its spread (Workowski et al.,2021).

Testing Recommendations and Treatment Options

NAATs are the most preferred method for diagnosing Chlamydia and gonorrhea due to their high accuracy. Management involves the administration of azithromycin 1g in a single volume or doxycycline 100mg in divided doses for one week. Patients should avoid sexual activity or intimacy while undergoing treatment and until symptoms subside (Workowski et al., 2021)Evaluation Of Adults Burning With Urination Discussion Paper. In the case of multiple sexual partners, it is advisable to undergo routine tests for STIs.

ICD-10 and CPT Codes

Lower genitourinary tract chlamydial infection (ICD-10: A56.01) CPT: 99203 (office visit with new patient, moderate complexity). The patient’s new patient status and the visit’s complexity—which calls for a thorough history and examination—are included in the justification.

Patient Education, Medical/Legal Concerns, and Interprofessional Collaboration

Education should include aspects of regular condom usage, regular STI checks as well as notifying partners. Stress on the need to finish the full prescription of antibiotics and not engage in sexual activity during treatment (Rawlinson et al., 2021). Legally, if STIs are not diagnosed and treated, they may cause several complications, such as infertility, chronic pain, and an increased likelihood of passing the disease to others; this leaves patients with the possibility of suing for medical malpractice. Regarding interprofessional collaboration, additional departments like the infectious disease department for complex cases, urology for chronic complaints, and counseling for safe sex can add much value to patient care Evaluation Of Adults Burning With Urination Discussion Paper.

References

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An Overview of Reviews on Interprofessional Collaboration in Primary Care: Barriers and Facilitators. International journal of integrated care, 21(2), 32. https://doi.org/10.5334/ijic.5589

Sadoghi, B., Kränke, B., Komericki, P., & Hutterer, G. (2022). Sexually transmitted pathogens causing urethritis: A mini-review and proposal of a clinically based diagnostic and therapeutic algorithm. Frontiers in medicine, 9, 931765. https://doi.org/10.3389/fmed.2022.931765

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 70(4), 1–187. https://doi.org/10.15585/mmwr.rr7004a1 Evaluation Of Adults Burning With Urination Discussion Paper

Chief Complaint
“Burning with urination.”

History of Present Illness
A 21-year-old man presents as a new patient for an evaluation of burning with urination for 3 days. He states he noticed it to be mild at first and thought maybe it was just irritation from a new soap he was using, but then it worsened. He also notes a small amount of clear penile discharge. When he had these same symptoms a few months ago, he went to a local DOH and was given antibiotics but does not remember the name. His symptoms went away immediately after treatment then, and he has been fine until this present concern. The patient’s sexual history reveals he is active with both women and men but predominantly men. He has no current primary sexual partner, and he states having about five male sexual partners in the past 3 months. When he does have sex with men, he states he is primarily a “top” (insertive) partner with anal sex and both give and receive oral sex. Regarding condom use, he says he never uses condoms with oral sex and does not always use condoms during anal sex, depending on how much he trusts his partner. His last HIV test was 4 months ago during a student testing initiative; it was negative Evaluation Of Adults Burning With Urination Discussion Paper.

Review of Systems
Positive ROS findings as noted in the HPI. The ROS is negative for fever, chills, SOB, chest pain, abdominal pain, or rash.

Relevant History
The patient’s medical history is significant for mild intermittent reactive airway disease controlled with an albuterol inhaler PRN. He uses an inhaler only occasionally, about once every couple of months. He is a social drinker at parties on weekends, rarely uses marijuana or edibles, and has no history of tobacco use or vaping. He has had no surgeries and is a senior in college with plans to pursue a PhD when he graduates. He denies any experimentation or use of other substances like methamphetamines, cocaine, opiates, or others. His family history is noncontributory. Evaluation Of Adults Burning With Urination Discussion Paper

Allergies
No known drug allergies; no known food allergies.

Medications
Albuterol inhaler 2 puffs every 4–6 hours PRN.

Physical Examination
Vitals: T 36°C (97°F), P 82, R 12, BP 113/82, WT 100.7 kg (222 lbs), H 180.3 cm (71 in.), BMI 31.

General: Thin male in no acute distress.

Psychiatric: Slightly anxious behavior noted.

Skin, Hair, and Nails: No notable rashes or lesions.

Abdomen: Soft, non tender, not distended, active bowel sounds, no masses felt.

Genital/Rectal: Uncircumcised male, able to retract foreskin easily. Clear discharge when instructed to milk the shaft. No lesions or rashes noted. Shotty bilateral inguinal lymphadenopathy noted, scrotum with mild tenderness when palpating left testicle. Both testicles are smooth with no evidence of masses or nodules. Valsalva maneuver reveals no hernia on either side. Rectal exam deferred. Evaluation Of Adults Burning With Urination Discussion Paper

Clinical Discussion Questions
What is the differential diagnosis?
What is the most likely diagnosis? Why?
Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.
Should tests/imaging studies be ordered? Which ones? Why? Think about tests/imaging beyond the primary care setting as well.

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What are the next appropriate steps in management?
What are the testing recommendations, treatment options, and screening guidelines for this diagnosis? Provide references for your response.
What are the pertinent ICD-10 and CPT (E/M) codes for this visit? Provide a short rationale.
What is the appropriate patient education for this case?
If not managed appropriately, what is/are the medical/legal concern(s) that may arise?
Think about interprofessional collaboration for this case. Provide a list of specialties or other disciplines and indicate what contribution these professionals might make to managing the patient Evaluation Of Adults Burning With Urination Discussion Paper