776966 Topic: HA W11 R1
Number of Pages: 1 (Double Spaced)
Number of sources: 2
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Writing Style: APA
Type of document: Essay
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776966 Topic: HA W11 R1 Number of Pages: 1 (Double Spaced) Number of sources: 2 Writing Style: APA Type of document: Essay Academic Level:Master Category: Nursing Order Instructions: Patient: Male 56 years old History and physical Chief complaint: complaining of a white milky discharge from his penis HPI: unprotected sex with a woman he met in Las Vegas. The discharged started 4 days ago and he is experiencing pain with urination Past medical history:HTN and Inguinal hernia Surgeries: none Medications: HCTZ Allergies: NKDA Review of systems: HEENT: denies any head trauma,denies any vision problems, denies any denies rhinorrhea, denies epistaxis, denies sore throat, denies any hearing issues Respiratory: denies any cough, sputum production, SOB, wheezing Cardiovascular: Denies any chest pain, palpitations, or edema in extremities GI: Denies any vomiting, diarrhea, constipation, abdominal pain GU: white milky discharge from his penis, pain with urination, denies hematuria, sexually active, Musculoskeletal: denies any pain, swelling to joints Skin: denies any rashes, wounds, sores, Assessment: Vital signs: BP: 130/76 HR: 88 RR: 18 Temp: 98.6F SPo2: 98 Weight: 190 lbs. Height: 5’9” HEENT head normocephalic, no abnormalities to scalp Eyes: PERRLA, EOMI CN-intact Ears: Right normal canals tympanic membrane clear, Left normal canal tympanic membrane clear Nose: no deviations noted or evidence of epixatis Throat: tongue midline, normal pharynx, normal voice, Neck: no thyroid enlargement, no carotid bruits Chest: normal breath rate, lungs clear in all lobes Heart:heart rhythm regular, normal heart sounds S1and S2, no murmurs or extra sounds heard no chest rub, capillary refill less than 3 seconds, no edema present Abdomen:soft, flat, no masses Genitalia/rectum: white milky penile discharge , no lesions, Testes descended bilaterally, smooth, without masses and Epididymis is nontender. Right Inguinal hernia nontender, able to reduce. Musculoskeletal: intact reflex in all extremities, stable gait, Skin:warm, dry, no open ares, rashes, Social Hx: nonsmoker, nondrinker, travels extensively and has never had this problem before. Collect a gram stain Diagnosis: Nongonococcal Urethritis, Chlamydia Education: Safe sex practices, nutrition, exercise, refrain from sexual activity until 7 days after medication therapy is completed Plan: Azithromycin 1g PO x 1 dose The patient in the scenario presented with signs and symptoms of Chlamydia infection. Chlamydia is a Sexuallaly transmitted Infection that is acquired thru unprotected sexual activity. Chlamydia can cause vagina and penis discharge . Chlamydia can also cause reproductive system harm in females like PID, inability to get pregnant and ectopic pregnancy(STD Facts – Chlamydia, 2017). Patient need education on how prevent future infection, and the need to treat their partners also. The patient can be treated with antibiotics. References: STD Facts – Chlamydia. (2017, October 4). Retrieved from https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm ** PROVIDE RESPONSE WITH REFERENCES. ALL REFERENCES MUST BE WITHIN LAST 5 YEARS OF PUBLICATION AND IN APA FORMAT.