HISTORY:
Urethral discharge for
Type: ,
, up to °, over
Sexually active:
Condom use:
Number of partners in the last year:
Last STI screening:
STI risk factors:
no history of urethritis
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
ASSESSMENT:
DDx:
PLAN:
- STI screening for chlamydia and gonorrhea
- Urinalysis
- Urine culture
- Blood work: , , ,
-
- Sexual partners treatment
- Abstinence until treatment completed and symptoms resolved
- Condom use
- Proper hygiene
- Referral to urologist
- Follow-up in
- Return if symptoms do not improve or if develops fever or abdominal pai