CC: "I am experiencing pain in my lower abdomen, which extremely hurts when I urinate, and also, I now have a fever."
HPI: Patient C is a presentable, 36-year-old Caucasian male reporting to the office for complaints of pain in his back and abdomen. The patient also complains of pain while urinating for the last three days. He describes the pain as excruciating. Patient C had taken Acetaminophen and has been consuming cranberry juice. However, the symptoms have been worsening. The day before coming for a checkup, Patient C experienced cold before he started to sweat and states that he feels warm to touch; however, he has not measured his body temperature using a thermometer. Patient C gauged the pain in his lower abdomen on a scale of five to ten. He further declines to have a history of STI, UTI, or HIV infection. He denies any history of recent catheterizations or procedures. Patient C's last sexual encounter was a month ago. He denies anal intercourse.
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Medication: Acetaminophen to relieve pain and lower fever.
: Allegra 60 mg for managing seasonal allergies
PMHI:
Allergies: Seasonal allergies
Past Surgical History: No history of surgery.
Medication Intolerances: Denies any known medical intolerances
Major Trauma: Involved in a car crash when he was in High School
Immunizations: The patient is up to date with all required vaccinations such as Influenza and Tetanus.
Family History: Father and Mother are alive; however, they were divorced when Patient C was nineteen years old. He lost contact with his father. The patient's mother is in her sixties and has onset symptoms of CVDs and hypertension. Patient C has a brother and sister who are both employed. Sister, age thirty, is married and has two kids and lives a fulfilling life. Brother, aged 42, struggles with alcohol addiction and depression. The brother had lost several jobs due to alcohol problems and is currently employed in a thrift shop. The maternal grandmother is still alive and is aged 105 years with Alzheimer's disease. The paternal grandfather, aged 72, is still alive and housed a nursing home and is suffering from diabetes.
Social History: Patient C states that he is a very social person and spends most of his time hanging out with friends. He loves sports, enjoys playing baseball, and he also loves zip-lining with friends. He works fulltime as an accountant and recently promoted to the position of a senior accountant. He is currently single after breaking up with his girlfriend of two years about a month ago. He currently resides alone in a two-bedroom apartment. Patient C denies having a history of smoking. Patient C denies the use of illicit drugs. Patient C admits to taking beer and drinks a few bottles over the weekend, especially when attending events with friends.
HEALTH CARE MAINTENANCE: Patient C goes to the gym to stay fit. Patient C has never gone for a PSA check. Patient C has not gone for a testicular examination for about two years now.
ROS:
General: Patient C complains of fever. He shows an expression of pain in the lower abdomen. Patient C denies weight change. Patient C denies night sweats. Patient C denies headaches. Patient C denies adenopathy. Patient C, in general, appears tired and malaise.
Skin: Denies discoloration of skin or bleeding. Admits to simple bruising and delayed healing
Cardiovascular: Denies cardiac palpitations or chest pain. Patient C denies dyspnea or SOB . Patient C denies any symptoms associated with claudication
Respiratory: Patient C denies any cough, wheezing, or SOB.
HEENT: Patient C denies sinus pressure or pain and also any tension or pain in the ear
GIT: Denies a loss of appetite. He denies constipation, abdominal pain, nausea, vomiting, or diarrhea. The patient denies hematochezia. He denies abnormal bowel movements. He denies distention, bloating, or fullness.
Genital: Patient C admits to pain at the tip of the penis. He denies dyspareunia or penile discharge. He denies the presence of sores, lesions, or bumps around the perineum. He denies pruritus. The patient denies infections around the pelvic.
Urinary: Patient C reports discomfort when urinating, perineal pain, cloudy urine, an urgency to urinate, and frequent urination. He denies flank pain, hematuria, nocturia, malodor, and discharge.
Neurological: The patient denies seizures, syncope, or loss of sensory or motor control. The patient reports he has a good memory.
Musculoskeletal: The patient admits to having pain in his lower back. He denies arthralgias or myalgias.
Psychiatric : He denies a history of depression or suicidal thoughts.
OBJECTIVE:
Vital Sign: Height 70 inches, weight 170 pounds. BMI: 24, pulse oximetry 99 percent at rest on RA. BP 122/54 HR: 76 bpm. Body temp: 38 ο C, orally.
General appearance: Patient C appears healthy, masculine, very focused, and very confident during the checkup. He is well presentable with neat hair and beard and engaged in the consultation. He appears calm and maintains eye contact throughout.
Skin: Had smooth and moist with just minor bruises.
HEENT:
Head: Normocepahalic. Normal hair pattern and distribution and has a coarse texture. No bald regions. Sinus tenderness absent after percussion.
Ears: Hearing is normal. He has normal ear pinnae devoid of scars, piercings, rashes, or masses. Negative for Frank's sign noted bilaterally. Tympanic membranes have a good cone of flight.
Eyes: Intact extraocular movements. No conductivities and slightly red eyes. PERRLA.
Nose: Normal appearance and shape. No erythema, exudate, or swelling. The patient has a normal septum and mucosa. Sinus tenderness absent.
Throat: Intact lower and upper dentures. No lesion or exudate in the oral mucosa .
Neck: Supple neck. No rashes or deformities. Trachea midline. Normal voice. No adenopathy, submandibular or supraclavicular lymph nodes (Hogan-Quigley, Palm & Bickley, 2018)
Cardiovascular: Normal S1 and S2 sound heard. Normal heart rhythm and rate. Auscultated S3 and S4 absent. Normal PMI location and amplitude. Brisk carotid upstrokes devoid of bruits identified bilaterally. Tenderness of the ribs absent after palpitation. Chest wall mass and crepitus absent.
Respiratory: Regular and symmetrical chest expansions during respiration. No proof of distress or use of accessory muscles. No observed rales, rhonchi, or wheezing. Tactile fremitus absent.
GIT: Abdomen is flat, non-tender, and soft. No observed ascites. Regular bowel sounds and available in all four quadrants. Hepatomegaly absent. Splenomegaly absent. Positive CVAT identified.
Genitourinary: Penis appears normal with regular urethral placement. No edema noted in the testes, and no lesions masses or nodules observed. Both testes palpable Pubic air coarse pubic air distributed normally. Pain confirmed in the suprapubic region after palpation.
Rectal/Pelvic: Prostrate firm, war, and tender after DRE. Nodules or masses absent.
Musculoskeletal: Normal posture and gait. A normal range of motion in all extremities. No observed pain during gait or movement. +2 pulses observed in bilateral upper extremities of radial and branchial. +2 pulses observed in the bilateral lower extremities of PT and DP. Brisk capillary refill. No observed clubbing of nails or cyanosis. Extremity edema absent. Sufficient turgor of the skin. No observed varicosities in bilateral lower extremities. No rashes identified. No ulcers or stasis pigmentation detected.
Neurological: Speech is coherent. Stable gait and normal posture. Intact Cranial nerves II-XII.
Psychiatric: The patient is alert, attentive, and has no signs of distress.
(Hogan-Quigley, Palm & Bickley, 2018)
Lab Tests: A urinalysis dipstick test was conducted and indicated positive for nitrates and leukocytes (Magistro & Nickel, 2019). Also, a urine sample of the patient was sent for gram stain in addition to serum PSA, and blood culture to discount bacteremia.
Differential Diagnosis:
Urethritis (ICD 10 code N34.1). The primary complaint was dysuria; however, this was ruled out because the patient denied other claims such as urethral meatus discharge and pruritus, which are universal proofs for urethritis. Also, no secretion was noted by the patient after the penis was "stripped" gently, implying gonococcal urethritis (Kovalyk & Ekusheva, 2019)
BPH (ICD 10 code N40.1) was excluded since it frequently occurs in men aged fifty years and above. Also, men often manifest LUTS that comprise storage, voiding, and irritative signs (Kovalyk & Ekusheva, 2019).
UTI (ICD 10 code N30.90) was excluded since chills fever, constitutional symptoms, for example, malaise or fatigue, are not UTI-like symptoms. Also, DRE does not reveal prostatic tenderness (Kovalyk & Ekusheva, 2019).
Diagnosis: Acute Bacterial Prostatitis, Class I (ICD 10 code N41.0), was conducted grounded on clinical manifestations, urinalysis results, and physical evaluations.
PLAN:
Further diagnosis testing: The significance of this follow-up testing is to avoid sepsis and further hospitalization. Imaging studies are only necessary for acute bacterial prostatitis if the prostatic abscess is suspected (Magistro et al. 2016).
Medication/Treatment plan: Prescription of Ciprofloxacin 500 mg tablets, by mouth twice every day for two weeks until gram stain and blood culture finding are obtained, and the therapy is to change after the pathogen has been identified (Magistro et al. 2016). Follow up PSA tests to determine if they are normal.
Patient Education: The patient was enlightened on the need to adhere to the prescribed antibiotic medications. The patient was instructed to consume more fluid and to have adequate rest (Magistro et al. 2016). The patient was further advised to abstain from alcohol during this period to avoid dehydration. He was also advised against engaging in sexual activity or masturbation to avoid increased itching of the prostate.
Non-medication Treatments: Psychological support was provided to the patient as part of supportive therapy. The patient was also informed about the importance of having friends around during this period for support (Magistro et al. 2016). The patient was also given an emergency number if he needed any psychological help from the physician or other help towards his recovery.
References
Hogan-Quigley, B., Palm, M. L., & Bickley, L. S. (2018). Bates' nursing guide to physical examination and history taking.
Kovalyk, V. P., & Ekusheva, E. V. (2019). Chronic prostatitis: differential diagnosis. Case report discussion. Journal of Clinical Practice , 10 (2), 85-90.
Magistro, G., & Nickel, J. (2019). Evaluation of chronic prostatitis/chronic pelvic pain syndrome.
Magistro, G., Wagenlehner, F. M., Grabe, M., Weidner, W., Stief, C. G., & Nickel, J. C. (2016). Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. European urology , 69 (2), 286-297.
