What additional history should you obtain from the patient?

I would inquire about the onset and duration of his symptoms, the severity of his pain including when the pain and swelling started, and any recent trauma to the scrotum. I would also inquire about details regarding his sexual activity, including the use of protection and recent sexual encounters. I should obtain a detailed sexual history, including any history of sexually transmitted infections (STIs) and his partner’s sexual health status. Additionally, I would inquire about any urinary symptoms, such as burning sensation during urination or changes in urinary frequency. According to Van-Ommen et al. (2023), obtaining a sexual history is vital for providing thorough care to individuals showing symptoms of (STIs) as it helps assess the risk of STIs, decide on the necessity for screening, address any concerns, and offer sexual health education.

What physical examination components are indicated for this presentation?

For this presentation, the indicated physical examination components would include inspecting and palpating the scrotum and penis for tenderness, swelling, redness, discharge, or skin lesions. Examination of the inguinal lymph nodes is also essential to assess for any enlargement or tenderness. According to Dunphy et al. (2022), during the examination of a male patient, the healthcare provider assesses the penis, glans, urethra, scrotum, and anal area for any abnormalities and the presence of redness, swelling, or any lesions during this examination may suggest the possibility of a sexually transmitted infection (STI).

Based on the presentation and history, you recognize the need to screen for sexually transmitted infections (STIs).  What are the most common STIs for this presentation?

Given the patient’s symptoms and sexual history, screening for common STIs such as gonorrhea and chlamydia is imperative in this case as these infections often present with similar symptoms making them key considerations in this case. Gonorrhea and Chlamydia are the most common STIs associated with urethritis, penile discharge, and scrotal pain and swelling in sexually active young males (Dunphy et al., 2022).

After your assessment, all subjective and objective findings should be considered when developing differential diagnoses for scrotal pain and swelling with accompanying urinary complaints. What may be included on a differential list?

In developing a differential diagnosis for a patient presenting with scrotal pain and swelling as well as urinary complaints, considerations may include epididymitis, chlamydia, gonorrhea, urinary tract infection, urethritis, prostatitis, and testicular torsion (Dunphy et al., 2022). Each of these conditions presents with distinct features that must be carefully evaluated based on the patient’s history and examination findings (Dunphy et al., 2022).

Name your priority diagnosis and provide the treatment plan. If you elect to treat with medications, provide full prescription details and follow up plan.

Priority diagnosis for this patient would be gonococcal infection based on the finding of purulent discharge and overall presentation. Upon confirmation of infection, the treatment plan would involve prescribing antibiotics to eradicate the infection and prevent complications. Treatment for gonorrhea encompasses a combination of antibiotics such as ceftriaxone 250 mg IM once and azithromycin 1 gram orally as a single dose (Dunphy et al., 2022). Follow-up plans would include advising the patient to return for a follow-up visit in 1-2 weeks to assess treatment response, monitor for any adverse effects, and ensure resolution of symptoms. Additionally, I would educate the patient on safe sexual practices and the importance of partner notification and treatment (Dunphy et al., 2022).

As the practitioner, you are required to report certain STIs to your state health department. Provide a list of the STI’s that must reported in your state along with the information that needs to be included when reporting these.

STIs that must be reported in Florida encompass a range of infections, including syphilis, AIDS, chlamydia, gonorrhea, chancroid, granuloma inguinale, hepatitis A and B, HIV, and lymphogranuloma venereum (Florida Department of Health [FDH], 2024). When reporting these cases, required details to report include patient demographics such as name, age, sex, race/ethnicity, the date of diagnosis, type, and stage of the STI, laboratory confirmation information, treatment provided or prescribed, and patient contact details for partner notification and follow-up (FDH, 2024).

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