What is (are) the most likely diagnosis (diagnoses)? What were the clinical findings that confirmed the diagnosis (diagnoses)?

NSG6435 Week 10 Discussion

Aquifer case titled  Internal Medicine 14: 18-year-old female for pre-college physical .

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What is (are) the most likely diagnosis (diagnoses)? What were the clinical findings that confirmed the diagnosis (diagnoses)?

 

The most likely diagnoses for Ms. Pham include acute cystitis and chlamydia.  The patient’s history and physical exam reveal positive indicators for these diagnoses. The patient is experiencing acute onset of mild midline suprapubic tenderness, urinary frequency, dysuria, and hematuria, which is consistent with cystitis (Li & Leslie, 2021).  The dipstick urine test is positive for leukocyte esterase, nitrates, and hemoglobin.  Aside from the urinary symptoms, the patient also reports she recently had unprotected sex with one partner. The patient’s pelvic exam results indicate the patient is positive for chlamydia.

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How is it (are they) treated according to the most recent clinical guidelines? Cite the guidelines.

 

The first-line empiric therapy for non-complicated cystitis include: Nitrofurantoin 100mg PO BID for 5-7 days, Sulfamethoxazole-trimethoprim (SMX-TMP) double- strength PO twice a day for 3 days, Fosfomycin 3 grams single oral dose (Li & Leslie, 2021).  With that being said, I would treat the patient with Nitrofurantoin 100 mg PO BID for 5 days (Li & Leslie, 2021).  First line therapy for chlamydia includes; Doxycycline 100 mg PO BID for 7 days or Azithromycin 1-gram one-time oral dose (Mohensi et al., 2021).  Given the likelihood for adherence to finish the treatment, I would prescribe Azithromycin 1-gram one-time oral dose to treat Ms. Pham’s chlamydia (Mohensi et al., 2021).

 

Describe a plan of care for the patient, including patient education, and additional tests.

 

As previously mentioned, the patient should be treated for chlamydia and acute cystitis with Nitrofurantoin and Azithromycin.  It is also imperative that Ms. Pham encourage her partner to be tested and treated for sexually transmitted diseases.  Once her partner has been tested and treated, they should avoid sexual contact for seven days after being treated for chlamydia (CDC, 2021).  Additional education includes: increasing fluid intake, avoid coffee, alcohol, soft drinks, and citrus juices until infection has cleared to lessen bladder irritation (Mayo Clinic, 2021).  I would also offer Ms. Pham Phenazopyridine 200 mg PO TID as needed to alleviate/decrease the severity of symptoms associated with cystitis (Mayo Clinic, 2021).  The patient should return if she is experiencing worsening symptoms, fever, vaginal discharge, vomiting, severe abdominal pain, flank pain, or any other concerns.

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