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Abstract: A 22-year-old male patient reported that he had been feeling painful urination for 3 days, and the discomfort was more pronounced during urination, accompanied by frequent urination, without symptoms of urinary urgency, meatus hematuria, fever, or lumbar pain, and because the discomfort was more pronounced, he sought medical help.
Basic information】Male, 22 years old
Disease Type】Urethritis
Hospital】The First Hospital of China Medical University
Time of consultation】March 2017
Treatment plan】Medication (cefoxitin sodium for injection, levofloxacin hydrochloride sodium chloride injection)
Treatment period】5 days of in-hospital treatment and 3 months of outpatient follow-up
Treatment effect】The condition was effectively controlled, no painful urination and frequent urination
I. Initial consultation
When I first saw the patient, he complained of painful urination 3 days ago for no reason, sometimes light and sometimes heavy, and the discomfort was more obvious during urination. The patient had no previous history of hepatitis, hypertension, heart disease, etc. During physical examination, it was found that after squeezing the patient’s penis, there was a yellowish discharge from the outer orifice of the urethra, and there was dirty and dry discharge from his underwear.
II. Treatment history
I first informed the patient that the cause of his painful urination and urgency was bacterial infection of the urethra, causing urethritis, and that the patient had no history of allergy to antibacterial drugs. I prescribed anti-infective drugs, namely cefoxitin sodium for injection and levofloxacin hydrochloride sodium chloride injection, so as to control the spread of inflammation as well as to achieve the purpose of eliminating inflammation, in order to prevent further spread of the infected lesion at the urethra, which would make the condition more serious instead. The patient also said he would actively cooperate with the treatment.
The effect of treatment
On the first day of medication, the patient’s condition improved, he was clear and in good spirits, his urinary pain and frequency were reduced, and the discharge from the urethra was less than when he was admitted to the hospital. On the third day of drug treatment, the patient’s temperature was 36.2℃, pulse rate was 78 times/minute, respiration was 19 times/minute, painful and frequent urination had basically disappeared, and there was no purulent discharge from the urethral orifice. On the 5th day of drug treatment, the patient’s sleep and diet were better, and his condition was effectively controlled, with no urinary pain and frequency, so he was discharged.
IV. Precautions
1. I was happy to see that the patient’s symptoms were reduced, and advised the patient to avoid eating spicy and stimulating foods, such as chili, spicy pot, strong coffee, etc., during the treatment process, and to choose to eat light, nutrient-rich foods, such as winter melon, mustard, banana, chicken, bean skin, etc. Also drink more warm water to wash the urethra by increasing the number of urine discharges to assist in the improvement of the condition.
2. I inform patients that if they usually find a tendency for the disease to worsen, such as urinary pain becoming heavier, they should promptly explain to me, and then I will choose a more targeted treatment plan according to the changes in their condition.
V. Personal insight
Urethritis is a disease that usually cannot be cured on its own, but if targeted treatment is taken in the early stages of the disease, the disease will be cured, just like the 22-year-old male patient in this case, who did not blindly use medication after discovering his abnormal painful urination and frequent urination, but promptly sought medical examination and treatment, which led to good control and alleviated the discomfort caused by the disease, and I saw the patient happily discharged from the hospital. I also feel very relieved when I see patients discharged happily.