29-Sexual history (Male)

Urethral discharge / dysuria

Mr. Kamel is a 30-year-old male, presented with urethral discharge. You have 7 minutes to take a history,
present your findings and explain your management plan and answer any question he may have.
⬛ Risk factors for STIs:
⬛ Unprotected sexual intercourse
⬛ Multiple sexual partners
⬛ "15-24" year-olds
⬛ Illicit drug use and alcohol use
⬛ Men who have sex with men (MSM)
⬛ Sex workers
⬛ Urban areas

⬛ Start = Introduction:
Good morning, I am dr. Hani Waheb Hammouda, ED registrar, may I know your name and age, please?
Mr. Kamel, a 30-year-old
Nice to meet you Mr. Kamel, I have been asked to take some data from you regarding your sexual history, this is
going to involve me asking some personal questions, these are questions we ask of everyone and anything you
would tell me will be confidential. If you would prefer not to answer a particular question or you’d like to stop the
consultation at any point, please let me know, would it be ok with you? Yes, it’s ok
Anyone attend with you? No
Would you mind if a nurse attend with us as a chaperon? it’s ok
Do you have any pain, so I will offer pain killer for you? No, it’s ok
How can I help you today? I have a urethral discharge
Oh, I am sorry for that.
Verbalize: I need to check vital signs
The examiner: vital signs are normal

Open question: Can you tell me more about that urethral discharge?
⬛ Presenting Complaint History: ODIPPARA
O: Onset: How did it start, suddenly or gradually? Gradually
D: duration: When did it start? Yesterday Do you still have urethral discharge? Yes
I: Intensity: Is it affecting activities of daily living? Yes
P: Progression: Is it worsening, improving or same? Worsening Is it continuous or on and off? On and off
P: Previous episodes: Did you have same problem before? Yes
A: Aggravating factors: Does anything worsen it? I have no idea
R: Relieving factors: Does anything improve it? I have no idea
A: Associated features = Review of Systems
⬛ Associated symptoms = Review of Systems: 1-4
1-Urogenital: Do you have frequent, difficulty or painful urination, dark urine or blood in urine?
2-Dermatology: Any rashes, skin changes, pain or swelling in penis, testicles or anus?
3-Miscellaneous: Do you have high T, night sweats? Any lump in your body or did you lose weight or appetite?
Are your immunizations UpToDate e.g. A, B or HPV vaccination?
4-GIT: Do you have nausea or vomiting? If so with blood? Do you have throat pain, tummy pain, or yellowing of
the skin or eyes? Change of bowel movement, dark stool or Blood in stool?

⬛ Sexual History: 6 Ps HIV risk assessment: “Yes" is high risk

If you’d like to stop the consultation at any point, please let me know, would it be ok with you? Yes, it’s ok

Are you currently sexually active? Yes

1-People:
With whom? Wife
Do you have any other partner/s? Yes
How many partner/s over the past year? 3
Men, women or both? Women if “men”, Are you giving or receiving sex? Giving and receiving sex
How much do you know about your partner/s?
Have you or any of your sexual contacts exchanged money for sex? Yes, she is a sex worker
Any of your partners from a different country? Yes
Any of your partners a bisexual man or engaged in male homosexual activity? Yes
Any of your partners a known to be HIV positive? Yes
Any of your partners injecting drugs? Yes
2-Pregnancy: Are you trying to get your partner pregnant? Yes
3-Protection: Was it protected sex e.g. condom? Yes
4-Practice: When was the last sexual act? 2 days ago
Do you have vaginal, anal or oral sex? All
Was this sexual encounter consensual? Were you by any chance under effect of alcohol or any illicit drugs? Yes
5-Past: Have you or your partner/s ever been tested or diagnosed for HIV, or other STDs? Yes
Would you like to be tested? Yes
6-Problems: anything else about your sexual practices I need to know to ensure your good health?

⬛ Associated symptoms = Review of Systems: 5-8

5-CVS: Chest pain, Heart racing or Dizziness?
6-Respiratory: SOB, fast, noisy breathing or Cough? If so, with blood?
7-CNS & PNS: Do you have Headache, jerky movements, Faints, Vision problem or did you lose your
consciousness?
8-MSK: Body pain, back pain, weakness, paralysis or Recent trauma?
⬛ Past Medical History:
Do you have any current or past medical disease or recent hospital admissions?
Do you have any current or past medical disease e.g. High BP or High BM? Yes
Brain, Thyroid, Heart, liver or Kidney disease? Malignancy or blood disease e.g. leukemia? No
Asthma? Any recent hospital admissions? If so, when and why?

⬛ Past Surgical History:

Do you have previous surgery, camera scan, imaging or heart tracing?
Do you have any previous surgery e.g. Brain, thyroid, heart or tummy surgery?
Any investigations taken before e.g. camera scan for food pipe or stomach, tummy Imaging or heart tracing

⬛ Drug and Allergy History:

Do you take any prescribed medications e.g. Antibiotic, pain killer or blood thinning medications e.g. Aspirin,
Plavix or Warfarin? Do you have any allergy?

⬛ Family History:
Any diseases that run in your family .e.g. Malignancy, brain, heart or thyroid disease?

⬛ Social History:
Whom do you live with? Where do you live?
Do you smoke, drink alcohol or by any chance, do you use any illicit drugs?
What do you do for living?
Can you manage self-hygiene/housework/food shopping?
Any social support or mobility aids?

⬛ Travel History:
Have you travelled anywhere recently? No
If yes,
Where did you travel? Malaysia/ Thailand where did you stay rural or urban?
When did you travel? 1 month ago when did you return? 1week ago
Did you eat seafood, raw food or homemade food?
Did you notice any insect or animal bites? Yes
Did you drink or swim in contaminated water? Yes
Did you have recent contact with someone who is sick? Yes
Did you have a pretravel immunization or chemoprophylaxis? Did you use a mosquito net? No

⬛ ICE:
What do you think regarding your symptoms, what is your concern, what do you expect from us to do?
I am worried. do I have a sexual transmitted infection?

⬛ Differential Diagnosis:
Mr. Kamel, I appreciate your concern and it’s our concern also, I am sorry to tell you that according to your
DATA, you have a high risk of sexual transmitted infection including HIV
⬛ Management Plan:
Mr. Kamel, we need to keep you in observation room, check your vital signs, do general physical examination and
examine your tummy, penis, testicles and anal canal as well. And I would like to run some tests e.g. BM, heart
tracing, blood tests e.g. FBC, kidney, liver function, coagulation profile, blood gases, U/A and urethral swab to
figure out the exact cause of your symptoms and then discuss Post Exposure Prophylaxis After Sexual Exposure
which must be started within 72 hours after a recent possible exposure to HIV and the appropriate treatment with
you. And I will arrange appointment with GUM clinic for follow up and you should notify your sex partner/s in case
you are diagnosed with STD or HIV and till the results you should avoid sexual intercourse and blood transfusion

⬛ END:
Mr. Kamel, did you understand what I have told you to be sure that I correctly explained to you?
Yes, it’s ok, I understood
Would our management plan be ok with you? Yes, it’s ok
Do you have any further question/s? No, thank you
Thank you, wash my hands

Thank You
Dr. Hani Waheb Hammouda