Urinary Symptoms

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of urinary symptoms

Symptoms include:

‍dysuria

‍frequency

‍urgency

‍foul-smelling urine

‍hematuria

‍suprapubic pressure

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍flank pain

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍incontinence

‍hesitancy

‍nocturia

‍vaginal discharge, ‍clear, ‍thin, ‍withwithout fishy odor

‍urethral discharge

‍testicular pain



Last menstrual period: ‍ ‍daysweeksmonths ago

Contraception: ‍yesno ‍oral contraceptives

Condom use: ‍alwayssometimesnever

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍pregnancy

‍menopause

‍sexually active

‍poor personal hygiene

no history of: ‍urinary tract infections, ‍kidney stones, ‍prostate enlargement, ‍neurological disorders, ‍urological surgery, ‍pelvic radiation, ‍diabetes

no use of: ‍recent antibiotic use, ‍immunosuppressant drugs, ‍diuretics, ‍opioids, ‍new medications





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia





ASSESSMENT:

‍Urinary tract infection ‍likelysuspectedpossible

DDx: urinary tract infection, overactive bladder, interstitial cystitis, prostatitis, urethral stricture, bladder stones, neurogenic bladder, benign prostatic hyperplasia, urinary retention, kidney stones, sexually transmitted infection, diabetes mellitus, bladder cancer, cystocele, pelvic organ prolapse, medication side effect, excessive fluid intake, constipation, pelvic floor dysfunction, spinal cord injury, neurologic condition





PLAN:

Investigations:

- Urinalysis

- Urine culture

- Blood work: ‍CBC, ‍creatinine, ‍CRP

- Pelvic ultrasound

- CTA of abdomen and pelvis

Treatments:

- ‍Antibiotics

- ‍Other urinary medications

- Increase fluid intake

- Avoid caffeine, alcohol, and spicy foods

Further care:

- Referral to urologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if fever develops