Patient’s name: Alex Grange
Age: 21 years old male
Past medical history
Drug history and Allergies
Recent notes/consultation
Patient booked routine appointment to discuss concerns
You are Alex grange, a 21-year-old male. You have noticed burning sensation when you pass urine and getting a bit of discomfort around your penis.
This has been ongoing for last 3 days. ONLY SAY BELOW IF ASKED.
You had unprotected sex 10 days ago with a new partner you met on a dating site (Only volunteer this if asked).
You are otherwise well. SAY NO TO ANY OTHER SYMPTOMS ASKED
Social history: you do not smoke or drink alcohol or use illicit drugs. You work as a Software developer
Ideas- You suspect a urine infection
Expectations: You need antibiotics
Questions for the doctor
If you are asked to come in for a face-to-face consultation or drop in a urine sample;
inform the doctor that you cannot come in and that You are due to travel to Dubai for an important tech meeting for your Job in the next 30mins and you are currently on your way to the airport. You will be back from Dubai in 2 weeks’ time.
History taking
Explain to patient; Alex, from everything you’ve described, including the burning sensation when passing urine and your history of a new sexual partner, it’s very likely that you have a sexually transmitted infection, or STI. This is something we can treat effectively, but it’s also important to confirm the diagnosis and check for other possible infections.
Ideally, I would like you to come in so we can do a urine test and screen for other STIs.
However, since you’re traveling to Dubai and won’t be able to come in right now, I will prescribe you an antibiotic called doxycycline. This should help treat the likely infection and manage your symptoms.
While this is a good start, I strongly recommend that you get tested for other STIs as soon as you can. You could do this in Dubai if it’s convenient for you, or we can arrange it as soon as you return. Screening is really important to ensure your complete health and also to protect any current or future partners
Management