NR 509 4.1. – NJL, 22, M, African American

NR 509 4.1. – NJL, 22, M, African American

Patient Information:

NJL, 22, M, African American, Cigna

S.

CC: “burning sensation while peeing and peeing constantly”

HPI:    Onset: 2 days ago

Location: urethra

Duration: intermittent r/t urination

Characteristics:  burning, frequent urination

Aggravating Factors: urination

Relieving Factors: Tylenol 250 mg

Treatment:  Tylenol 250 mg orally Twice a Day

Current Medications: none

Allergies:  None

PMHx:  TDaP  06/5/13.  Does not recall any other immunizations.  Denies any major illnesses or surgery.

Soc Hx:   Truck driver student, enjoys hanging out with friends and playing sports.  Long-term relationship, one son age 6 month, non-smoker, EtoH 3 drinks/week.  Patient plays basketball 3 days a week. NR 509 4.1. – NJL, 22, M, African American.

Fam Hx: NJL is the middle child of three. One son, 6 months, healthy.  One sister 34 and one brother 28,  no known health disorders. Father 61, smoker, Obese, Hypertension, Hyperlipidemia. Mother 59, Hypertension, Hyperlipidemia. Maternal Grandmother 75 (deceased), skin cancer. Maternal Grandfather (deceased) alcoholic, diabetic unknown age of death. Paternal Grandmother 86, no health issues. Paternal Grandfather (deceased) diabetic.

ROS: (Jarvis, 2016)

CONSTITUTIONAL:  Denies any weight loss, fever, chills, weakness or fatigue.

HEENT:

Head: Denies head injury, dizziness, syncope, vertigo, or severe headaches.

Eyes:  Denies any difficulty, eye pain, inflammation, lesions, visual loss, blurred vision, double vision or yellow sclera, glaucoma, cataracts, no corrective lenses.

Ears: Denies hearing loss, earaches, discharge, tinnitus or vertigo NR 509 4.1. – NJL, 22, M, African American

Nose:  Denies epistaxis discharge, sinus pain, obstruction or allergy.

Throat:  Denies mouth pain, bleeding gums, toothache, lesions in mouth, dysphagia.

CARDIOVASCULAR:  Denies cyanosis, chest pain, pressure or discomfort, palpitations or edema, hypertension, anemia. Denies history of murmur, dyspnea with exertion, or coronary artery disease.

PERIPHERAL VASCULAR: Denies pain, numbness, tingling, coldness, discoloration, varicose vein, infection, ulcers or swelling in legs.

RESPIRATORY:  Denies shortness of breath, wheezing, or chest pain with breathing. Nonsmoker. Denies history of lung disease. (Smoker 1pack/week)

MUSCULOSKELETAL: Denies history of arthritis, gout, joint pain, stiffness, swelling, muscle pain, weakness or limitation of motion.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.  Reports no change in bowel or bladder control.

GASTROINTESTINAL: Denies nausea, vomiting or diarrhea. No abdominal pain or blood. Denies history of ulcers, gallbladder disease, appendicitis or colitis. Bowel movement 1/day, soft, brown no pain or bleeding.

GENITOURINARY:  Denies kidney disease, flank, groin or suprapubic pain. No reports of dysuria, frequency, hesitancy or urgency. Denies change to urine color. Denies pain, lesions , lumps or discharge from penis and scrotum. Monogamous 3- year heterosexual relationship with condoms for contraceptive. No other sexual partners reported. Denies any known contact with partners with STIs. (Dysuria, frequency- 8 times/day)

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.  Reports no change in bowel or bladder control.

MUSCULOSKELETAL: Denies history of bone trauma, joint pain, deformity, gout or arthritis.

HEMATOLOGIC:  Reports no history of intravenous drug use, blood transfusions, anemia, bleeding or irregular bruising. NR 509 4.1. – NJL, 22, M, African American.

LYMPHATICS:   No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies polyuria or polydipsia

 

O.

Physical exam:

Height 177.8 cm (6’0), Weight 77.27 kg (170 lbs.). BMI: 23.1

NJL is a 22-year-old African American male of appropriate weight, who is not currently under the influence of drugs or alcohol who articulates clearly, ambulates without difficulty and appears to be in no distress.

HEENT

HEAD: Normocephalic, symmetrical face no weakness or involuntary movements. No tempromaxillary joint tenderness noted upon palpation.

EYES:  PERRLA. EOM intact, no ptosis, discharge or crusting.  Conjunctivae clear, sclerae white; no lesion or redness. Pupils 3mm brisk reaction.

EARS: No mass, lesions, discharge or tenderness to palpation. Clear canals. Tympanic membrane boggy clear fluid noted, landmarks intact, no perforation NR 509 4.1. – NJL, 22, M, African American.

NOSE: No deformities or tenderness to palpation, mucosa pink, septum midline.

THROAT:  Mucosa and gingivae pink, no lesions. Tongue symmetric and midline. Tonsils present

NECK: Supple with full ROM, no masses, tenderness, lymphadenopathy, no jugular veins distention or carotid bruits.

RESPIRATORY:  All lungs fields clear to auscultation. No wheezing. Chest expansion symmetrical. Tactile fremitus equal bilaterally.

CARDIOVASCULAR:  no abnormal pulsations, no heaves, Apical impulse at 5th ICS in left MCL, S1-S2 present, no murmur auscultated

PERIPHEAL: Color appropriate for racial background; No redness, cyanosis, edema, varicosities, or calf tenderness.  Radial, Posterior tibial, Dorsalis pedis pulses palpable 2+ and equal bilaterally.

MUSCULOSKELETAL:  Temporomandibular joint-no slipping or crepitation. Neck- Full range of motion, no pain. Vertebral column- No tenderness, curvature or deformity: full extension, lateral bending and rotation. Arms and legs symmetric bilaterally with full range of motion, no pain or crepitation. Able to maintain flexion against resistance and without tenderness.  Upon inspection of muscles throughout body no atrophy noted. Homologous muscles equal bilaterally in size, strength and tone.

NEUROLOGIC: Appearance behavior speech appropriate. Alert and oriented to person, place, time, with coherent thoughts.  Cranial nerves I-XII intact. Reflexes intact 2+ bilaterally.

GASTROINTESTINAL: Flat, symmetric, bowel sounds present in all four quadrants. No tenderness upon palpation. No masses or organomegaly noted. (Suprapubic tenderness upon palpation)

GENITOURINARY:  Penis-  Circumcised, skin intact without inflammation, lesions or nodules. No phimosis or paraphimos. Urethral meatus centrally located. Pubic hair distribution appropriate without lice or nits. Meatus edge open, pink, smooth and without discharge. No tenderness, nodules or induration palpated on penis shaft. No scrotal edema or inflammation present, slight asymmetry noted-left testicle lower than right testicle. Testes oval, firm, smooth, equal bilaterally and slightly tender to moderate pressure. Smooth nontender spermatic cord. No hernia, tumor, or varicocele present. No hernia or bulge present upon palpation of left and right inguinal canals or while patient is standing or straining down on. Inguinal lymph nodes soft, discrete and movable. Urine pale yellow, pH 7.0, SGravity 1.020, negative protein, glucose, WBCs, RBCs.  (Cloudy yellow urine, pyuria, bacteriuria, slight tenderness upon palpation of inguinal lymph nodes and suprapubic area)

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.  Reports no change in bowel or bladder control.

MUSCULOSKELETAL: Denies history of bone trauma, joint pain, deformity, gout or arthritis.

HEMATOLOGIC:  Reports no history of intravenous drug use, blood transfusions, anemia, bleeding or irregular bruising. NR 509 4.1. – NJL, 22, M, African American.

LYMPHATICS:   No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

 

 

According to Domino & Baldor (2016), urinary tract infections or Cystitis is an infection of the lower urinary tract usually resulting from gram negative enteric bacteria and is characterized urinary frequency, urgency, dysuria, low back pain, hematuria, flank pain, urine dribbling, nausea and vomiting and suprapubic discomfort. General treatment includes hydration, and pain medication/ analgesics as needed.  Occhipinti, Germano, & Maffei (2016) found that a dose of Oximacro, 112 mg BID x 7 days, which contains 36 mg A type cranberry proanthocyanidins was effective in preventing UTIS.  In uncomplicated cystitis a fluoroquinolone or sulfa drug may be used for 7 days while in complicated cystitis a 2-week antibiotic selected from culture and sensitivity results is recommended (Domino& Baldor, 2016).

 

 

Domino, F. J., & Baldor, R. A. (2016). The 5-minute clinical consult 2017 (25th ed.).

Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins

Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Retrieved from

http://bookshelf.vitalsource.com.

Occhipinti, A., Germano, A., & Maffei, M. E. (2016). Prevention of urinary tract infection with   oximacro, A cranberry extract with a high content of a-type proanthocyanidins: A          pre-      clinical double-blind controlled study. Urology Journal, 13(2), 2640-2649. NR 509 4.1. – NJL, 22, M, African American.

 

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