Patient Information: AP, 35, F, Caucasian.
S. CC “blood in the urine.”
HPI: A 35-year-old Caucasian female presents to the office with complaints of blood in the urine. The symptoms started a week ago, and the patient also experiences pain during urination and increased frequency. She does not report any exacerbating factors. The patient tried taking Tylenol and hydrate to relieve pain. Today, the patient woke up to pee and noticed some blood in her urine. The patient rates her pain as 4/10 on a pain scale.
Current Medications: Tylenol, oral 500 mg as needed for pain.
PMHx: No major illnesses or surgeries, last Td booster 2015, Influenza vaccine October 2019, all immunizations are up to date.
Soc Hx: The patient works as a manager at a grocery store. She is married, no children. The patient quit smoking about five months ago, previously smoked 10-12 cigarettes for around 13 years. AP admits to drinking recreationally with her spouse and friends, but no more than once a week. The patient has a good support system; she lives in an apartment in the city and has two dogs. AP says that she does not have much time to cook and often eats pre-made meals.
Fam Hx: Both parents are alive; the mother is 62, has deep vein thrombosis. The father is 61, has hypertension. The patient has a younger brother, 29, no pertinent conditions, healthy.
- GENERAL: No weakness or fatigue, no weight loss or weight gain, no chills.
- HEENT: Eyes: No changes in sight, blurred or double vision, no yellow sclerae. Ears, Nose, Throat: No hearing loss, congestion, runny nose, sneezing, sore throat.
- CARDIOVASCULAR: No chest pain, discomfort, or pressure. No edema or palpitations. No history of hypertension.
- RESPIRATORY: No dyspnea, cough, or sputum.
- GASTROINTESTINAL: No vomiting, anorexia, or nausea. Slight pain in the pelvic region, no abdominal or flank pain.
- GENITOURINARY: Urinary frequency, dysuria, and urgency for the past week. AP states that she had to urinate at least eight times during some days. Burning on urination, discomfort during sexual activity, but no irritation. The patient is sexually active and has one long-term partner. She never had urinary tract infections before. LMP 10/22/2019.
- NEUROLOGICAL: No change in bladder or bowel control, no headache or dizziness.
- PSYCHIATRIC: No history of mental health problems.
- ENDOCRINOLOGIC: No polyuria or polydipsia. No polydipsia or polyuria, no sweating, heat, or cold intolerance.
- ALLERGIES: AP denies any allergies to food, drugs, environment, or animals. No eczema or asthma.
O. Physical exam:
- GENERAL: The patient appears nourished and well-groomed; she is dressed for the weather appropriately. She is alert and oriented, answers questions cooperatively and clearly.
- VITAL SIGNS: BP 125/79 mm Hg, P 81, R 16, T 98.6 F, Height 5’8”, Weight 175 lbs., BMI 26.6
- HEENT: Eyes: Clear, white sclerae, 20/20. Ears, Nose, Throat: Clear, no inflammation, not tender, no mucus.
- CARDIOVASCULAR: No gallops, murmurs, or rubs. S1, S2 present, no S3 or S4.
- RESPIRATORY: The lungs are clear, no wheezing.
- GASTROINTESTINAL: The abdomen is soft, non-tender to touch, no palpable masses, bowel sounds present in all quadrants.
- GENITOURINARY: No CVA tenderness, slight tenderness in the suprapubic area.
- NEUROLOGICAL: Reflexes +2 symmetrical, balance and gait normal.
Diagnostic results: The first test is dipstick urinalysis to measure the urine’s pH, protein, glucose, nitrites, white blood cells, bilirubin, and blood (Tharpe, Farley, & Jordan, 2017). This diagnostic can detect a variety of problems, pointing to such diagnoses as urinary tract infection (UTI), diabetes mellitus, kidney stones, kidney infection, and liver disease (Schuiling & Likis, 2017). The second test is urine culture to find any bacteria in the urine, suggesting an infection (Tharpe et al., 2017). If these diagnostics do not lead to conclusive results, a CT scan, an ultrasound, or an MRI may be necessary to inspect the urinary tract (Schuiling & Likis, 201). These tests are also necessary to diagnose kidney stones and cancer.
- Cystitis (UTI). Cystitis is a common urinary tract infection that affects the bladder (John, Mboto, & Agbo, 2016). It is more prevalent in women than men due to the location of the genitourinary system. The main signs of cystitis include burning and pain on urination, frequency, urgency, lower abdomen or pelvic pain, and hematuria (blood in urine) (John et al., 2016). The patient’s symptoms fully align with the infection’s presentation, and her physical examination reveals the tenderness of the suprapubic region, which points to the inflammation of the bladder (Grabe et al., 2015). The results of the dipstick test and urine culture should support this primary diagnosis.
- Acute Pyelonephritis. This condition develops when the infection of the urinary tract reaches the kidneys (Johnson & Russo, 2018). The symptoms of pyelonephritis are similar to those of cystitis, but the patient can also experience flank pain or back pain, nausea and vomiting, fever, and chills (Johnson & Russo, 2018). The patient’s examination does not show CVA tenderness, which lowers the possibility of a kidney infection (Grabe et al., 2015). The patient also does not have a fever, chills, or back pain. Thus, this diagnosis is less likely, and the tests should eliminate it.
- Kidney Stones (Ureterolithiasis). Kidney stones are deposits that can form in the kidneys (Simon, Maxwell, & Bailey, 2017). Their development may be asymptomatic, causing pain and discomfort only during passing. The signs are back or side pain, pain during urination, smelly urine, urgency, nausea and vomiting, fever and chills, and hematuria (Simon et al., 2017). The patient’s pain is not as severe as it is common for ureterolithiasis, and she does not have a fever or chills. If the main diagnostics do not show a sign of infection, an ultrasound or CT can reveal the stone.
The diagnostics for the primary diagnosis of cystitis included a dipstick urinalysis and urine culture. The primary diagnosis was chosen based on the patient’s history, physical examination, and positive tests. The pharmacological treatment includes Bactrim DS, orally, 1 tablet every 12 hours for 10 days (“Bactrim dosage,” 2018). This antibiotic is necessary to combat the infection, and patient education is needed since she has to complete the course to avoid complications or reoccurrence (Grabe et al., 2015). Furthermore, the patient should continue to drink plenty of water, avoid alcohol, soft drinks, and coffee for the duration of the treatment (Vecchio, Iroz, & Seksek, 2018). Some alternative remedies include cranberry juice, which is believed to help with UTIs (Vecchio et al., 2018). Overall, the patient may avoid sexual intercourse during treatment and apply warmth to the pelvic area to alleviate discomfort. A follow-up in ten days is scheduled to check for any symptoms.
UTIs are common among women, and their untimely treatment can lead to severe complications. In this case, the patient’s symptom of blood in urine could be a sign of a much more serious condition. In a similar evaluation, I would follow the same steps, including some additional information about previous diseases and sexually transmitted infections to broaden the list of differential diagnoses. Overall, this experience allowed me to work with one of the most widespread problems in female health.
Bactrim dosage. (2018). Web.
Grabe, M., Bartoletti, R., Bjerklund-Johansen, T. E., Çek, M., Köves, B., Naber, K. G., … Wult, B. (2015). Guidelines on urological infections. European Association of Urology, 182, 237.
John, A. S., Mboto, C. I., & Agbo, B. (2016). A review on the prevalence and predisposing factors responsible for urinary tract infection among adults. European Journal of Experimental Biology, 6(4), 7-11.
Johnson, J. R., & Russo, T. A. (2018). Acute pyelonephritis in adults. New England Journal of Medicine, 378(1), 48-59.
Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.
Simon, J. C., Maxwell, A. D., & Bailey, M. R. (2017). Some work on the diagnosis and management of kidney stones with ultrasound. Acoustics Today, 13(4), 52-59.
Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.
Vecchio, M., Iroz, A., & Seksek, I. (2018). Prevention of cystitis: Travelling between the imaginary and reality. Annals of Nutrition and Metabolism, 72(2), 8-10.