Free Essay Comprising Patient Interview and Establishing a Diagnosis

Source of History: The patient is the source of history and appears reliable.

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C.C: 'I have an irritation on my penis for the past one week. These is after masturbating, and the feeling has been persistent for the past one week.'

HPI: X, is an 18-year old male, who presents to the clinic complaining of an irritation of the penis after masturbating. The feeling has been persistent for the past one week, and he described the annoyance as a burning sensation on the penis which was accompanied by an itchy feeling when urinating. The itchiness would stop after some time after urinating, and these would then disappear after a while. The irritation is on the severity of 6/10 and was experienced in the urethra part of the penis, and it would be accompanied by a painful itchy feeling when and after urinating.

Essential negatives: The patient has no history of sexually transmitted diseases, has a long distance girlfriend and has foul smelling urine.

Adulthood diseases: No BP, no diabetes, no familial illness, no whooping cough, no blood transfusions.

Psychiatric illnesses: none

Accident and injuries: none

Operations: none

Hospitalization: none

Current medication: none

Allergies: no food/ drug allergy

Social history

Drugs: no hard drug abuse, no smoking, takes alcohol occasionally

Relationship: has a girlfriend and they use condoms, no children, currently living with parents.

Residence resides in a hostel in college.

Occupation: He is a full-time student.

Family history: None has severe conditions

Reviews of systems

General: no changes in sleeping pattern, no other change due to the irritation, no mild fatigues

Skin: Normal, no changes

Head: no head rush, no headaches, no dizziness

Eyes: No eye pain, god sightings, last time y had an eye check was three years ago with a 20/20 vision.

Ears: no problems with hearing, no discharge

Genital: does not deny self-examination, claims there is no color change and the irritation is on the urethra according to his diagnosis.

OBJECTIVE

General survey: the patient is well oriented with place and time, no signs of complications whatsoever.

Assessment Diagnosis: Urinary tract infection

Urinary tract infection may occur several times in a year depending on the environment a person lives in and the level of cleanliness maintained. In Y's case, it is the first time to encounter such, and these might have been a result of low-level hygiene when he was masturbating hence some bacteria's might have made way into the urinary tract. In this case, cleanliness seems to be the primary concern. The patient should complete the dosage given to avoid a future relapse of the condition.

Differential diagnosis: Sexually transmitted infections, urinary tract infections.

The patient's urine should be tested to check for any signs of bacteria and conduct an abdominal ultrasound to check for kidney stones if found the patient should be advised to take up to three glasses of water daily. If none is detected, the patient should stick to the dosage provided for by the doctor or physician and should avoid masturbation.

References

Schaeffer, A. J., & Nicolle, L. E. (2016). Urinary tract infections in older men. New England Journal of Medicine, 374(6), 562-571. Retrieved from

http://www.nefroinfo.com/medicos/Articulos/2016/Febrero/IVU%20en%20el%20anciano.%20NEJM.pdf

Rowe, T. A., & Juthani-Mehta, M. (2014). Diagnosis and management of urinary tract infection in older adults. Infectious disease clinics of North America, 28(1), 75. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079031/