Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Urinary symptoms (burning with urination, dysuria), frequent urination (frequency), urgency to urinate, or pain at the tip of the penis
(urethral discharge may or may not be present).
History of Present Illness:
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Onset, duration, and severity of urinary symptoms.
Character of any urethral discharge (color, consistency, amount).
Frequency and urgency of urination.
Hematuria (blood in the urine) (present/absent).
Risk factors for sexually transmitted infections (STIs) (new sexual partner, unprotected sex).
Prior episodes of urethritis or STIs.
Past Medical History:
Underlying medical conditions (e.g., urologic abnormalities).
Prior surgeries (urethral procedures).
Social History:
Sexual history (number of partners, condom use).
Recent antibiotic use (may mask symptoms of underlying infection).
Family History:
Not typically relevant for non-gonococcal urethritis.
Physical Exam:
General examination: Assess for fever (suggestive of acute infection).
Genitourinary examination:
Inspect the penis for urethral discharge or redness.
Palpate the urethra for tenderness.
Examine the testicles for swelling or tenderness (epididymitis
complication).
Laboratory Tests:
First-catch urine test: Urinalysis to assess for white blood cells
(WBCs) indicating inflammation and possible infection.
Gram stain of urethral discharge (if present): Can identify gonococci
(bacteria causing gonorrhea) but not other pathogens. A negative gram stain
does not rule out non-gonococcal urethritis.
Urethritis PCR panel: Molecular test to detect specific pathogens
causing non-gonococcal urethritis (e.g., Chlamydia trachomatis, Mycoplasma genitalium).
Imaging Studies:
Imaging studies are not typically used for diagnosis of non-gonococcal urethritis unless complications are suspected (e.g., prostatitis).
Assessment:
Non-gonococcal urethritis: Based on clinical presentation (urinary symptoms) and negative gram stain for gonorrhea. Urethritis PCR panel results
pending to identify specific pathogen.
Possible causative pathogen (if identified by PCR): Chlamydia
trachomatis, Mycoplasma genitalium, or other less common pathogens.
Differential Diagnoses:
Consider other causes of urethral symptoms:
Gonococcal urethritis (ruled out by negative gram stain)
Prostatitis (inflammation of the prostate gland)
Urinary tract infection (UTI) (more common in females)
Balanitis (inflammation of the glans penis)
Plan:
Treatment is based on the suspected pathogen identified by urethritis PCR panel. Possible elements include:
Antibiotic therapy: Specific antibiotics are chosen based on the identified pathogen. Common regimens include azithromycin for
Chlamydia and doxycycline for Mycoplasma.
Patient education: Advise on completing the full course of antibiotics, avoiding sexual contact until treatment completion for both
themselves and their partner(s).
Repeat testing: Consider re-testing after treatment completion
to ensure eradication of the infection.
Prognosis:
Non-gonococcal urethritis is usually curable with appropriate antibiotic therapy. Early diagnosis and treatment are important to prevent complications such as epididymitis (inflammation of the testicles).
Follow-up:
Depending on the severity of symptoms and identified pathogen,
follow-up may be needed to monitor symptom resolution and ensure treatment
completion.