Elizabeth Varona-Martin

Module 4

Week 4

Clinical experience plays a vital role in our formation. It helps in expanding our knowledge and skills for providing safe patient care. My clinical experience this week was successful. The working environment was conducive and peaceful. I collaborated with other healthcare professionals to provide care, making our work easier . I felt more confident as patients were willing to share their illnesses with me, which caused me to develop different skills. I acquired new knowledge throughout the week that I will apply in the future as a healthcare provider.

The case I would like to share is a 68-year-old White man who presented to the office with a fever of 102.3^ F with chills, occasional nausea, poor appetite, difficulty urinating, and dysuria. It is accompanied by spontaneous perineal pain and during urination. There is no low back pain or hematuria. He reports a transrectal ultrasound-guided prostate biopsy was performed three days ago. He has no known history of nephritic colic, urinary tract infections, or sexually transmitted diseases. He does not have a history of drug allergies.

The examination highlights the suprapubic fullness with dullness to percussion. The renal percussion is negative. Genitals are normal, with no signs of inflammation or dermal alterations. The patient declined a digital rectal exam due to the discomfort.

Vital signs

Ht: 5’6 WT: 138.7 lb BMI: 22.5 Temp: 102.3 ^F

B/P: 122/80 HR: 88 bpm RR: 20 RPM O2Sat: 99%

Differential Diagnosis:

Lower urinary tract infection (UTI), or cystitis : In men who experience dysuria, urine frequency or urgency, and suprapubic pain, a urinary tract infection (UTI) should be suspected. However, fever, chills, rigors, and other indications of systemic diseases are not consistent with UTIs and elevate the probability of pyelonephritis, prostatitis, or another UTI complication (Hooton, 2021).

Urethritis : The most frequent complaint is dysuria or unpleasant urination and urethral discharge. Urethritis is usually seen in young, sexually active men. The most typically related organisms are Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium (Bachmann, 2021).

Epididymitis: Patients may present with dysuria, but the typical symptom of acute epididymitis is localized testicular pain with tenderness and swelling on palpation of the affected epididymis (Eyre, 2022).

Impression and Plan

Diagnosis

Acute prostatitis ICD 10-CM N41.0

Based on the data collected, the diagnosis of Acute prostatitis was made.

We ordered a CBC, CMP, urinalysis (U/A), urine Gram stain, and culture with sensitivity and initiated empiric antibiotic therapy with Bactrim (Trimethoprim-sulfamethoxazole 160mg/800mg) 1 tab orally every 12 hours for 14 days.

For pain we recommend the patient to use tylenol or ibuprofen. Use a heating pad or soak in a warm bath (sitz bath). We advised him to limit or avoid alcohol, caffeine, and spicy or acidic meals, all of which can irritate his bladder. Make sure to drink plenty of water to help him urinate more frequently, which will aid in the removal of bacteria from the bladder.

Follow up in 5-7 days to review lab results and evaluate response to the treatment. Patient was advised to call the office if symptoms worsened.

Referral to his urologist.

Health maintenance

Last influenza vaccine: 11/12/2021. Recommend it annually

Covid Vaccine Pfizer: 1/10/21 and 1/28/21.

Last Colonoscopy: 5/06/2015 due 5/2025

PSA: follow up by Urologist

Various inflammatory illnesses affect the prostate. Acute bacterial prostatitis, an acute prostate infection caused by gram-negative bacteria, is one of these disorders. Antimicrobial therapy forms an essential part of treatment due to the well-defined clinical presentation. Patients are usually very sick. Fevers, chills, dysuria, pelvic or perineal discomfort, and cloudy urine. Dribbling urine and other obstructive symptoms can also develop. The prostate is frequently hard, edematous, and extremely painful on examination. Peripheral leukocytosis, pyuria, and bacteriuria are frequent test results (Meyrier & Fekete, 2021).

Gram-negative organisms produce most cases, and initial antibiotic therapy should address this class. Providers recommend treatment with trimethoprim-sulfamethoxazole or a fluoroquinolone unless drug resistance is detected. Patient tolerance and regional trends of Enterobacteriaceae medication resistance should be considered while choosing between these options (Meyrier & Fekete, 2021).

References

Bachmann, L. H. (2021, October 7). Urethritis in adult males. UpToDate. Retrieved April 6, 2022, from https://www.uptodate.com/contents/urethritis-in-ad…

Eyre, R. C. (2022, March 14). Acute scrotal pain in adults. UpToDate. Retrieved April 6, 2022, from https://www.uptodate.com/contents/acute-scrotal-pa…

Hooton, T. M. (2021, October 6). Acute simple cystitis in men. UpToDate. Retrieved April 6, 2022, from https://www.uptodate.com/contents/acute-simple-cys…

Meyrier, A., & Fekete, T. (2021, October 25). Acute bacterial prostatitis. UpToDate. Retrieved April 6, 2022, from https://www.uptodate.com/contents/acute-bacterial-…