ESSAY HELP | 18-year–old female complaining of dysuria, suprapubic pain, urgency, and frequency.

Summary

18-year–old female complaining of dysuria, suprapubic pain, urgency, and frequency.

Denies fever, vaginal discharge, back pain, nausea, and vomiting.

Previously healthy, no medical or surgical history.

Last seen 3 months ago for a wellness visit prior to going to college.

Patient reports becoming sexually active.

Also reports using condoms most of the time.

HPI

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Dysuria, frequency, urgency, suprapubic pain for two days.

Patient reports noticing some blood in the urine this morning.

Denies fever, back pain, nausea, vomiting, and vaginal discharge.

Admits to recently becoming sexually active and having unprotected intercourse at times.

Medical History

NKDA

No previous medical history reported

No previous surgical history reported

Family History

Mother – healthy, no chronic conditions, alive.

Father – healthy, no chronic conditions, alive.

Sibling (younger) – healthy, no chronic conditions, alive.

Social History

College student

Lives in a dorm

Denies smoking

Reports drinking beer occasionally

Reports trying smoking weed one time

ROS

General: Denies fevers, fatigue, and/or malaise. 

Cardiovascular: Denies chest pain and/or palpitations.

Respiratory: Denies coughing and/or wheezing. 

Integumentary: No visible lacerations and/or wounds noted. 

Musculoskeletal: Denies joint pain, swelling, and/or stiffness. 

Breast: Denies masses and/or tenderness.

Gastrointestinal: Denies abdominal pain and/or N/V/D. 

Genitourinary: Patient reports urinary frequency and burning while urinating. 

Examination

General: Ms. Pham is a pleasant 18-year old female patient. Patient answers questions appropriately and presents as well groomed. 

Cardiovascular: S1/S2 with regular rate and rhythm, no MGR. Radial/peripheral bilaterally 2+. No edema noted. 

Respiratory: Lungs CTA, with no wheezing noted. 

Integumentary: Warm and dry. No wounds and/r lacerations noted. 

Musculoskeletal: Full ROM in all extremities. No lower back pain, tenderness, and/or deformities noted. 

Gastrointestinal: x 4 active bowel sounds. Mild midline suprapubic tenderness noted. No bladder distension noted. 

Examination continued

Breast: Free of masses, tenderness, and/or discharge. 

Genitourinary: Upon examination of genitalia via pelvic exam, no ulcerations, redness, and/or other abnormalities of the skin. Small to moderate amount of white of vaginal mucus noted. Otherwise, cervix normal in appearance. 

Heme/Lymph/Endo: Denies easy bruising and/or swelling of lymph nodes. 

HEENT: Head normocephalic with not facial tenderness. Eyes: PERRLA, sclera white. Ears: External canals clear bilaterally. Nose: Moist with no drainage. Mouth: Teeth in good repair, pharynx unremarkable. 

Neurological: Speech clear. Patient A/OX4. Gait steady. 

LABS

Labs

Urinalysis

Urine HCG

Chlamydia

N. Gonorrhea

HIV 

Vaginal Wet Mount/Vaginal Smear cells

Vaginal pH

Whiff-amine Potassium Hydroxide Preparation Test (KOH) 

Results

No yeast, trichomonads or clue 

Urinalysis is positive for leukocyte esterase, nitrates and hemoglobin 

Positive for chlamydia

Vaginal pH – 4.0

Whiff-amine Potassium Hydroxide Preparation Test (KOH) 

HCG negative

Diagnoses

PRIMARY

Acute Cystitis with Hematuria

Typical clinical presentation with urinary frequency, urgency, suprapubic pain, some hematuria, dysuria, and no fever. 

The urinalysis results show positive leukocyte esterase, nitrites, and hemoglobin.

DIFFERENTIAL

1.Cervicitis with Urethritis

Patient was positive for Chlamydia, which may be asymptomatic, or present with symtoms simialr to a UTI.

2.Pelvic Inflammatory Disease

Certain STIs may cause PID and symptoms consistent with clinical presentation of the patient, iincluding suprapubic pain, and dysuria.

3.Bacterial Vaginosis

 Dysuria which is a common symptom of BV.

Whiff-amine test was negative, which makes BV unlikely.

Management Plan

Nitrofurantoin 100 mg by mouth twice a day for 5 days.

Ibuprofen 600 mg every 6 hours by mouth as needed for pain relief.

Encourage patient to increase fluid intake.

Instruct patient to avoid full bladder.

Instruct patient to complete full antibiotic therapy.

Teach the patient to wipe “front to back”.

Instruct patient to return to the office if there are new and/or worsening symptoms.

Article 1

Douglas-Moore, J. L., & Goddard, J. (2018). Current best practice in the management of cystitis and pelvic pain. Therapeutic advances in urology, 10(1), 17-22.

This article highlights the etiology of cystitis  and a practical approach to the management of cystitis in clinical setting according to current guidelines. According to the authors, the management of this condition should be individualized and symptom-based; but, tends to follow a progressive therapeutic ladder. The article also rewies current therapeutic guidelines and treatment approaches. Ms. Pham presented with symptoms of dysuria, urinary frequency, and some hematuria. Her urine dipstick results strongly suggested a diagnosis of cystitis, and in turn would be treated with Nitrofurantoin which according to the article, is a first-line treatment option of choice.

Article 2

Young, C., & Argáez, C. (2017). Management and treatment of cervicitis: a review of clinical effectiveness and guidelines.

Young & Argaez review several evidence-based guidelines on cervicitis management. This article gives an insight on how cervicitis may be linked to gonorrhea or chlamydia. The clinical symptoms, diagnostic studies, and treatment guidelines are described in detail. Several pharmacological modalities are compared accounting effectiveness, adherence, and clinical outcomes. 

 The article is relevant to Ms. Pham’s case becausec it reviewes one of the differential dignoses in detail.

Article 3

Solomon, M., Tuchman, L., Hayes, K., Badolato, G., & Goyal, M. K. (2019). Pelvic inflammatory disease in a pediatric emergency department: epidemiology and treatment. Pediatric emergency care, 35(6), 389.

This retrospective, cross-sectional study reveals the consequences of unprotected intercorse and untreated STIs among adolescents. PID is one of the most serious complications of STIs. Rates of STI testing and appropriate treatment reveal gaps in diagnosis and management, representing a lost opportunity for identification and treatment of PID/STIs among high-risk adolescents. This article is relevant to Ms. Pham’s case because she tested positive for Chlamydia and is considered a high-risk group for STIs. 

Article 4

Shafii, T., & Levine, D. (2020). Office-Based Screening for Sexually Transmitted Infections in Adolescents. Pediatrics, 145(Supplement 2), S219-S224.

This article addresses the epidemiology of STIs in adolescents, reviews the evidence of current clinical practice, presents recommended STI screening from government and medical agencies, and offers strategies to address barriers to providing care for adolescents and for sexual health screening in primary care. This article adressess many important sensitive topics nessecary to address with adolescents and highlights importance of STI screening and timely treatment, like in Ms. Pham’s case.

Article 5 

Stone, L. (2018). Which antibiotics for UTI?. Nature Reviews Urology, 15(7), 396-396.

This randomized clinical trial  evaluates different treatment approaces among young females with symptomatic UTI. The primary outcome was clinical response – complete resolution of signs and symptoms of UTI. Secondary outcomes included bacteriological response and adverse events. Study has shown that 5-day nitrofurantoin is more likely to result in clinical and microbiological resolution of acute, uncomplicated lower urinary tract infection (UTI) than single-dose fosfomycin. This article supports ttreatment course selection for Ms. Pham. 

References

Douglas-Moore, J. L., & Goddard, J. (2018). Current best practice in the management of cystitis and pelvic pain. Therapeutic advances in urology, 10(1), 17-22.

Price, T. K., Hilt, E. E., Dune, T. J., Mueller, E. R., Wolfe, A. J., & Brubaker, L. (2018). Urine trouble: should we think differently about UTI?. International urogynecology journal, 29(2), 205-210.

Shafii, T., & Levine, D. (2020). Office-Based Screening for Sexually Transmitted Infections in Adolescents. Pediatrics, 145(Supplement 2), S219-S224.

References continued

Solomon, M., Tuchman, L., Hayes, K., Badolato, G., & Goyal, M. K. (2019). Pelvic inflammatory disease in a pediatric emergency department: epidemiology and treatment. Pediatric emergency care, 35(6), 389.

Stone, L. (2018). Which antibiotics for UTI?. Nature Reviews Urology, 15(7), 396-396.

Young, C., & Argáez, C. (2017). Management and treatment of cervicitis: a review of clinical effectiveness and guidelines.