Genitourinary
Case:
A 25-year-old woman presents for care and reports a 2-day history of burning with urination, urinary frequency, and feeling as though she is not emptying her bladder completely. She is sexually active with the same male partner for the past 4 months and is using a progesterone IUD for contraception.
Her past medical and surgical histories are negative, and she has no known drug allergies (NKDA).
She denies fever, chills, vaginal discharge, concerns about the IUD, or previous urinary infections or problems.
1. Explain what you would do for her during today’s visit and explain the expected outcomes
a. Assessment
b. Labs
c. Physica 3xam
d. Education
2. Based on the patient's clinical presentation
a. Explain the clinical diagnosis chosen for this visit
3. Treatment
a. Pharmacology
b. Nonpharmacology
c. Prevention strategies
In order to narrow down a diagnosis, laboratory tests may be ordered including urinalysis as well as culture and sensitivity testing if indicated. A physical exam should also be performed to rule out red flags that could indicate serious pathology such as pelvic inflammatory disease or kidney stones. The expected outcome of these assessments is to accurately diagnose the patient with either an uncomplicated cystitis or another more complicated condition if present.
Based on the clinical presentation, it is likely that this patient has acute cystitis caused by a bacterial pathogen due to her recent change in sexual partner and unprotected intercourse. Treatment options involve antibiotic therapy, pain control measures such as ibuprofen and rest, intake of fluids sufficient enough to flush bacteria from bladder walls, and heating pads for comfort. The expected outcome of treatment is improvement in symptoms within 1-2 days after initiating appropriate antibiotics.
Nonpharmacologic treatments can include avoiding tight clothing around the lower abdomen, using proper toileting techniques for urination such as wiping front-to-back after voiding, drinking cranberry juice or taking probiotics which are thought to help prevent UTIs from recurring by maintaining healthy gut flora balance; however their efficacy remains largely unproven . In addition education should focus on identifying signs associated with UTIs so that early recognition can lead to prompt treatment thereby preventing further complications as well implementing preventive strategies such as proper hydration levels adequate calcium intake along with practicing safe sex methods via consistent use barrier contraceptives like condoms female diaphragms etc when engaging in sexual activities outside monogamous relationships