Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping

Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping

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An 18-year-old female presents to the office complaining of dysuria, and lower abdominal cramping. She has no PMH, no allergies and No Primary Care Provider. LMP 2 months ago. PE reveals suprapubic tenderness on abdominal palpation. Denies flank tenderness on palpation. Develop a SOAP note and remember to include the differential Diagnoses and Diagnostics.
urine dip positive for leukocyte esterase and nitrates, pH 7.0, specific gravity 1.010, color dark yellow, clarity turbid Type Course Code Course Name University School Password School Email Username Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping

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Patient Particular’s

Initials: A.J

Age: 18years

Gender: Female

Ethnicity: American

Subjective Data

Chief complaint: lower abdominal cramping

History of presenting illness: A.J. is an 18years old American female at the emergency department complaining of lower abdominal cramping. The pain is of acute onset, sharp in nature, and radiates to the lower back. The aggravating factors are exertion and bowel movement which are relieved by rest and analgesics. The pain is worse when urinating. The pain is associated with dysuria, urine urgency, suprapubic tenderness, the sensation of bladder fullness, fever, chills, and rigors. The patient denies bilateral flank tenderness.

Past medical history: the patient has no record of

Allergies: none

Reproductive history: her menarche was at the age of 14 years. She has a 21-day regular cycle with four days of moderate flow. She is heterosexual and has one partner. She denies a history of sexually transmitted infection and the use of contraception. Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping

Review of systems

General: the patient denies fatigue, chills, rigors, and fever. She denies weight loss.

HEENT: she has no headache, blurring of vision, hearing loss, and nasal congestion.

Skin: she has no acne outbreak and stretch marks.

Cardiovascular system: the patient denies chest pain, palpitations, and lower limb swelling.

Respiratory system: she denies coughing, wheezing, and sputum production.

Gastrointestinal system: she denies abdominal pain, nausea, vomiting, diarrhea, and bloating.

Neurological system: the patient denies facial drooping, muscle weakness, and paresthesia.

Musculoskeletal system: the patient denies joint pain and stiffness.

Hematologic system: she denies recurrent infections and easy bruising.

Lymphatic system: the patient denies lower limb swelling.

Endocrinologic system: she denies heat intolerance and abrupt weight gain.

Objective data

Physical examination: the patient is alert and calm. She has no pallor, jaundice, cyanosis, or edema.

Vitals: her temperature is 38 degrees celsius, her blood pressure at 148/80mmhg, her pulse rate at 96 beats per minute, her respiratory rate at 20cycles per minute, and her BMI of 28kg/m². Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping

Respiratory system: the chest has symmetrical movement during respiration. There are vesicular breath sounds with no crackles, wheezing, or rhonchi.

Cardiovascular system: the peripheral pulse present a regular rate and rhythm. The heart sounds are present. There are no palpable heaves and thrills.

Gastrointestinal system: the abdomen is scaphoid. The bowel sounds are present in all four quadrants. There are no areas of tenderness.

Diagnostic investigations: urine dipstick is positive for leukocyte esterase and nitrates. The  PH is 7.0, specific gravity 1.010, the color is dark yellow, and the appearance is clarity turbid.

Assessment

Differential diagnoses

Urinary tract infection is significant bacteriuria in the bladder. It is the most common diagnosis in women visiting the emergency department. The causes of urinary tract infections are Escherichia coli, staphylococcus, klebsiella, and Enterococcus (Storme et al., 2019). The urinary tract is sterile and the bacteria invades the system by ascending through the vaginal introitus. The risk factors are female gender, immunosuppression, foreign bodies such as catheters, and sexual intercourse. The bacteria invade the bladder causing inflammation and systemic spread of the bacteria. The presenting symptoms are dysuria, urine urgency, suprapubic tenderness, the sensation of bladder fullness, fever, chills, and rigors (Storme et al., 2019)Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping. On investigations, there are characteristics of pyuria, a positive leukocyte esterase dipstick test, and low-grade proteinuria. The patient has a urinary tract infection.

Pyelonephritis is a bacterial infection of the renal parenchyma that may cause scarring of the kidney and eventually acute renal injury. Staphylococcus and klebsiella pneumonia is the most common pathogen-causing organism through hematogenous sources. The risk factors are endocarditis, intravenous drug abuse, recent surgical procedure, and pregnancy (Sundquist & Jansåker, 2021)Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping. The presenting symptoms are fever, costovertebral tenderness, nausea, vomiting, malaise, gross hematuria, bilateral flank pain, and anorexia. Pyelonephritis is more common in females than in males. More than 20% of pregnant women with asymptomatic bacteriuria develop pyelonephritis in their early and late trimesters. The patient presents with lower abdominal cramping and dysuria, however, she denies flank pain and costovertebral tenderness, therefore, ruling out pyelonephritis as a diagnosis.

Cervicitis is the inflammation of the uterine cervix due to local trauma or bacteria infestation. Non-infectious causes include cervical irritation from tampons and vaginal douches. Chlamydia trachomatis and Neisseria gonorrhea are the causes of infectious cervicitis (Suzuki et al., 2019)Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping. The risk factors are multiple sexual partners, young age, single marital status, and low socioeconomic status. The presenting symptoms are dysuria, polyuria, postcoital bleeding, fever, malaise, nausea, vomiting, dyspareunia, genital itching, malodor, and abnormal vaginal bleeding. The patient presents with similar symptoms. However, cervicitis is not the patient’s diagnosis because she denies vaginal discharge and genital itchiness. Moreover, she is not sexually active.

Plan

Diagnostic investigations

1. Urine culture and sensitivity to determine the pathogen causing the illness
2. Pregnancy diagnostic test -beta HCG to rule out early pregnancy
3. Pelvic ultrasound to rule out pyelonephritis and pregnancy

Pharmacological treatment

1. Tylenol 1000mg PO three times a day for five days
2. Nitrofurantoin 100mg PO three times a day for five days
   

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References

Storme, O., Tirán Saucedo, J., Garcia-Mora, A., Dehesa-Dávila, M., & Naber, K. G. (2019). Risk factors and predisposing conditions for urinary tract infection. Therapeutic advances in urology, 11, 1756287218814382. https://doi.org/10.1177/1756287218814382

Sundquist, K., Li, X., & Jansåker, F. (2021). Sociodemographic factors and uncomplicated pyelonephritis in women aged 15-50 years: a nationwide Swedish cohort register study (1997-2018). International Journal of Infectious Diseases, 111, 117-123. https://doi.org/10.1016/j.ijid.2021.08.009

Suzuki, S., Hoshi, S. I., Sekizawa, A., Sagara, Y., Tanaka, M., Kinoshita, K., & Kitamura, T. (2019). Current status of Neisseria gonorrhoeae cervicitis in pregnant women in Japan. Plos one, 14(2), e0211595. https://doi.org/10.1371/journal.pone.0211595 Case Study For Patient Complaining Of Dysuria And Lower Abdominal Cramping