Allergies to Penicillin (rash, itching, nausea, and vomiting)
Chief Compliant: UTI
Onset: Her UTI symptoms began three days ago
Location: Pain in the urethra 7/10
Duration: Reports increased urinary frequency
Characteristics: She has experienced pain during urination, a burning sensation, and increased
urgency to urinate. She is also experiencing some cramping in her lower abdominal region.
Aggravating Factors: Urination makes the pain worse
Relieving Factors: Drinks less water so she doesn’t have burning
Treatment: Cranberry pills, 3 days ago when symptoms started
Patient is a 21-year-old biracial woman presenting with an uncomplicated UTI. The onset took
place 3 days ago, located in the urethra with 7/10 for pain, and urinates frequently. Pt reports
pain with urination, a burning sensation and increased urgency, and cramping in lower
abdominal region. Aggravating factors include urination, reliving factors include drinking less
water to avoid burning, and self-treated with cranberry pills.
3 Differential Diagnosis
1) Cystitis - The clinical diagnosis of cystitis is made in a patient who has classic signs and
symptoms (ie, dysuria, urinary frequency, urgency, and/or suprapubic pain). For women
who have atypical urinary symptoms, the diagnosis is supported by the presence of pyuria
and bacteriuria on urinalysis and/or culture.
2) Urethritis - Evaluation for urethritis is warranted in sexually active women with dysuria,
particularly those with pyuria on urinalysis but no bacteriuria. Causes of urethritis in women
include chlamydia, gonorrhea, trichomoniasis, Candida species, herpes simplex virus, and
noninfectious irritants, such as a contraceptive gel.
3) Painful bladder syndrome – This is a diagnosis of exclusion in women who have
ongoing discomfort related to the bladder with symptoms of dysuria, frequency, and/or
urgency but no evidence of infection or other identifiable cause.
Review of Systems
Constitutional
- No fever
Gastrointestinal
- Reports lower ABD cramping
Menstrual Cycle
- LMP 2 weeks ago
- Last 4 days with light bleeding for 3 days afterwards
- MP are regular & predictable due to oral contraceptive
Genitourinary (GU)
- Urgency - Dysuria
- Burning - Polyuria
1
Chief Compliant: UTI
Onset: Her UTI symptoms began three days ago
Location: Pain in the urethra 7/10
Duration: Reports increased urinary frequency
Characteristics: She has experienced pain during urination, a burning sensation, and increased
urgency to urinate. She is also experiencing some cramping in her lower abdominal region.
Aggravating Factors: Urination makes the pain worse
Relieving Factors: Drinks less water so she doesn’t have burning
Treatment: Cranberry pills, 3 days ago when symptoms started
Patient is a 21-year-old biracial woman presenting with an uncomplicated UTI. The onset took
place 3 days ago, located in the urethra with 7/10 for pain, and urinates frequently. Pt reports
pain with urination, a burning sensation and increased urgency, and cramping in lower
abdominal region. Aggravating factors include urination, reliving factors include drinking less
water to avoid burning, and self-treated with cranberry pills.
3 Differential Diagnosis
1) Cystitis - The clinical diagnosis of cystitis is made in a patient who has classic signs and
symptoms (ie, dysuria, urinary frequency, urgency, and/or suprapubic pain). For women
who have atypical urinary symptoms, the diagnosis is supported by the presence of pyuria
and bacteriuria on urinalysis and/or culture.
2) Urethritis - Evaluation for urethritis is warranted in sexually active women with dysuria,
particularly those with pyuria on urinalysis but no bacteriuria. Causes of urethritis in women
include chlamydia, gonorrhea, trichomoniasis, Candida species, herpes simplex virus, and
noninfectious irritants, such as a contraceptive gel.
3) Painful bladder syndrome – This is a diagnosis of exclusion in women who have
ongoing discomfort related to the bladder with symptoms of dysuria, frequency, and/or
urgency but no evidence of infection or other identifiable cause.
Review of Systems
Constitutional
- No fever
Gastrointestinal
- Reports lower ABD cramping
Menstrual Cycle
- LMP 2 weeks ago
- Last 4 days with light bleeding for 3 days afterwards
- MP are regular & predictable due to oral contraceptive
Genitourinary (GU)
- Urgency - Dysuria
- Burning - Polyuria
1
