Reference no: EM133795176

Case: C.L , a 33-year-old woman, came to consultation complaining of dysuria, increased urine frequency, urgency, and moderate suprapubic pain, urine sample was taken, dispstick test was performed at the office and reported presence of nitrites and leukocytes , this along with symptoms presented are indicating an uncomplicated UTI. There were no positive findings on the physical examination. Her history of recurrent UTIs and lack of systemic symptoms like fever or chills corroborate this diagnosis. The quick start of symptoms, absence of vaginal discharge or itching, continuous condom usage, and steady sexual relationship make interstitial cystitis, vaginitis, and STIs less probable. For three days, Trimethoprim-Sulfamethoxazole is prescribed, UTI education is provided, and symptom remission is monitored.

Main Diagnosis: Uncomplicated Urinary Tract Infection (UTI) ICD-10: N39.0

This diagnosis is supported by the patient having symptoms of dysuria, urinary frequency, and urgency, along with mild suprapubic discomfort in conjunction with her history of recurrent UTIs (Bono et al., 2023). Without fever, chills, or flank/back pain, complicated UTI or pyelonephritis is less likely.

Differential Diagnoses

1. Interstitial Cystitis (ICD-10: N30.10)

IC is a chronic condition that mainly manifests with symptoms of bladder pain, discomfort, or pressure-usually accompanied by urgency and frequency of urination. Unlike a typical urinary tract infection, IC does not result from a bacterial infection; neither are standard UTI treatments effective. The exact cause of IC is unknown, but it is presumed to involve a defect in the lining of the bladder, immune responses, or problems with the nerves (Lim & O'Rourke, 2021). In this case, IC could be considered because the patient was describing discomfort to her bladder and had symptoms related to urination. In this scenario, though, IC is less likely because the onset of the patient's symptoms is more acute in nature and it more characteristically presents with a UTI. History of UTIs and no prior chronic pain to the bladder makes IC less likely. (Get Assignment help now)

2. Vaginitis (ICD-10: N76.0)

Vaginitis is an inflammation or infection of the vagina usually caused by bacteria, yeast, or other organisms. Vaginitis can cause symptoms that may include discharge in the vagina, itching, irritation, and pain on urination (Sheppard, 2020). The closeness of the vagina and the urinary tract may account for the fact that symptoms of dysuria and frequency can present similarly and thus may be mistaken for a UTI. It would thus also be in the differential diagnosis-as some of the symptoms of urinary abnormalities can present like those of vaginitis. However, in the case of vaginitis, it is not likely since the patient has no complaints of vaginal discharge, itching, or irritation-which are usually quite prominent in vaginitis. Further, she shows symptoms more related to discomfort associated with urination-a UTI.

3. Sexually Transmitted Infection (STI) ICD-10: A60.9)

Many sexually transmitted infections, including chlamydia and herpes, also have symptoms of dysuria, frequency, and pelvic discomfort. STIs should be a consideration in sexually active patients, especially if the history is one of unprotected sex and multiple partners. In this case, an STI is considered while noting the overlap in urinary symptoms; however, this patient has a stable sexual relationship and uses condoms consistently (Garcia & Wray, 2023). Also, the absence of potential symptoms from STIs, such as sores on the genitals, abnormal discharge of fluids from the vagina, or new sexual partners, reduces the chances that the patient's current symptoms originate from an STI.

PLAN

Diagnostics tests:

-Dipstick test was performed at office, showed presence of nitrites and leukocytes.

-Urinalysis + culture ordered, sample was sent to laboratory for processing.

Pharmacologic Treatment

Antibiotic: The patient should be prescribed Trimethoprim-Sulfamethoxazole (Bactrim), 160 mg/800 mg, 1 tablet bid × 3 days, in line with current guidelines pertaining to uncomplicated UTI.

Pain Relief: Ibuprofen 200 mg, continue as necessary for pain. Instruct not to exceed more than 1200 mg in a 24-hour period.

Non-Pharmacologic Treatment:

Increase fluid intake to help flush out the urinary tract. Advice regarding correct hygiene with regard to wiping correctly from the front to back and urination in case of sexual intercourse. Recommend wearing cotton underwear and avoiding tight-fitting clothes.

Patient Education:

Educate regarding the signs of an infection getting worse, such as fever, chills, or back pain that would require immediate medical attention.

Discuss why the full course of antibiotics should be taken, even when symptoms get better before the medication is gone.