When a patient appears with dysuria, a thorough history must be taken. The doctor must attempt to ascertain the symptoms’ onset, intensity, duration, and persistence (Mehta et al., 2021). For instance, discomfort at the start of urination may indicate a urethral condition such as urethritis. According to Mehta et al. (2021), the first history should include features of a probable local cause of dysuria, such as vaginal or urethral discomfort. Additionally, fever, chills, flank discomfort, low back pain, nausea, vomiting, joint aches, hematuria, nocturia, urgency, frequency, and incontinence should all be included in the patient history.
In order to gather more information about the patient’s condition, physical examination is crucial. A clinician should ask about the length of their symptoms if they have a history of recurrent UTIs, their current medicines, particularly analgesics, and any recent antibiotic usage, as well as any recent urethral instrumentation. A pelvic exam is not normally necessary, although it may be conducted to provoke suprapubic discomfort and rule out incomplete bladder emptying, urethral diverticulum, and other causes of symptoms, such as vaginitis (Peacher & Hardart, 2020). Additionally, tenderness of the costovertebral angles can also be evaluated if an upper tract infection is suspected. Peacher and Hardart (2020) state that the list of diagnostic tests will aid in making the patient’s diagnosis. To begin, when there is a high clinical suspicion of infection, an office urine dipstick should be performed. Secondly, a laboratory urinalysis will more reliably detect indicators of contamination such as pyuria, hematuria, and epithelial cells. Important to note that urine culture is the gold standard for detecting urinary tract infections (Chu & Lowder, 2018). Mehta et al. (2021) suggest that several conditions can produce dysuria through various methods. True dysuria must be distinguished from other symptoms, which might develop due to pelvic discomfort. Hence, the five possible conditions that may be considered in a different diagnosis are interstitial cystitis, prostatitis, suprapubic pain, retropubic pain, or sexually acquired reactive arthritis.
Regarding the subjective part of the note, more information should be provided on PSHx. According to Mehta et al. (2021), any history of risk factors such as pregnancy, the potential of a kidney stone, trauma, malignancy, recent urologic procedures, or the chance of urologic blockage should be considered. The documentation also should include health maintenance/promotion, review of symptoms, and GU (genitourinary). Peacher and Hardart (2020) emphasize that the objective portion of the note should include PE (physical exam), Gen (general statement of appearance), and GU (genitourinary). Diagnostic tests are mentioned, such as urine specimen collected and STD testing; nonetheless, for complex or recurring UTIs, urine culture with sensitivities should be done (Mehta et al., 2021). The assessment is supported by a diagnostic test mentioned in the objective part and PMH, HPI, CC from the subjective part. Nonetheless, more information is required for an accurate diagnosis.
Significantly, I would reject the current diagnosis because a physical exam was not performed and some crucial information was missing, as mentioned above. Cystitis, urethritis, pyelonephritis, and sexually transmitted diseases are infectious causes of dysuria (Mehta et al., 2021). Furthermore, vulvovaginitis and cervicitis can be causes of dysuria in females. UTI symptoms include dysuria, urine frequency, lower abdominal pain when filling the bladder, and urgency (Kim et al., 2019). Nonetheless, the disease severity classification was not mentioned: uncomplicated, complicated, or recurrent UTI (Peacher & Hardart, 2020). Pelvic congestion syndrome can be considered as a differential diagnosis for this patient. Jurga-Karwacka et al. (2019) state that the disease appears to be a condition that is underdiagnosed and undertreated. Moreover, it is frequently accompanied by urological symptoms such as hematuria, dysuria, and frequency of urination. The second possible diagnosis can be vaginitis, including yeast bacterial vaginosis with features such as vaginal discharge and/or pruritis (Peacher & Hardart, 2020). Ultimately, the third possible diagnosis is vaginal atrophy with vaginal dryness and irritation.
References
Chu, C. M., & Lowder, J. L. (2018). Diagnosis and treatment of urinary tract infections across age groups.American Journal of Obstetrics and Gynecology, 219(1), 40-51. Web.
Jurga-Karwacka, A., Karwacki, G. M., Schoetzau, A., Zech, C. J., Heinzelmann-Schwarz, V., & Schwab, F. D. (2019). A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain.PLoS One, 14(4). Web.
Kim, W. B., Lee, S. W., Lee, K. W., Kim, J. M., Kim, Y. H., & Kim, M. E. (2019). How women evaluate syndromic recurrent urinary tract infections.Urogenital Tract Infection, 14(2), 46-54. Web.
Mehta, P., Leslie, S. W., & Reddivari, A. K. R. (2021). Dysuria. StatPearls [Internet]. Web.
Peacher, A., & Hardart, A. (2020). Urinary Tract Infection.Obstetrics and Gynecology, 228–234. Web.