Dysuria and Lower Abdominal Cramping
Introduction
This paper analyzes the case of an 18-year-old female who presented with pain during urination and lower abdominal cramping. There is no significant past medical history. On examination, everything was normal. Dysuria and Lower Abdominal Cramping
Subjective Data
Chief complaint: dysuria and lower abdominal cramping.
HPI: Dysuria was of acute onset and repeated after every episode of urination with a burning sensation associated with polyuria, foul-smelling urine, and dark in color. Lower abdominal pain was of acute onset, diffuse in nature, radiating to the back, flank region, aggravated by exertion, and relieved by analgesics. It is associated with general body malaise and dull headache.
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Past medical and surgical history
No previous admission history, underlying chronic illness, minor or major surgeries. No known history of food or drug allergy.
Family social-economic history
The patient is 18 years old, living with her parents and siblings. She is in college, has never indulged in smoking cigarettes and drinking alcohol. No familial history of chronic illness. Parents and siblings are alive and healthy.
Gynecology and obstetrics history
Non-parous, with no history of pregnancy or abortions. Not using any form of family planning and has not indulged in sexual intercourse. Her menarche was at the age of 15 years. The cycle is regular at 28 days with a moderate flow for three days. Dysuria and Lower Abdominal Cramping
Review of systems
The affected system is the genital-urinary system with symptoms of polyuria, dysuria, urinary urgency and frequency, and lower abdominal cramping. Other body systems are not affected.
Objective Data
Vital signs are essential before making an impression. The temperature was 38.2 degrees Celsius, blood pressure at 98/50 mmHg, oxygen saturation at 98% 0ff oxygen respiratory rate at 14cycles per minute, and pulse rate was 82 beats per minute. On general examination from head to toe, there was no pallor, no jaundice, no dehydration, no cyanosis, no edema, no dehydration and, no lymphadenopathy.
Systemic examination.
Abdominal exam-non-distended, no palpable masses, non-tender on deep and light palpation
Pelvic exam-
Vaginal examination-
Laboratory Findings
Urinalysis- leukocytes, nitrites, ketones, and pus cells. Complete blood count shows elevated white blood cells count.
Assessment
, Primary Diagnosis-Urinary Tract Infection
Differential Diagnoses-Acute pyelonephritis, Bacterial vaginosis, Pelvic inflammatory disease. Dysuria and Lower Abdominal Cramping
Plan
Pharmacological
Painkillers for pain and fever relief
Oral antibiotics
Non-Pharmacological
Education on safe sex
Education on hygiene
Drink plenty of water
References
Ayala, I. A., &Adegite, E. (2020). Complications of Heavy Menstrual Bleeding in Adolescents. In Hematology in the Adolescent Female (pp. 99-108). Springer, Cham.
Ma, J., Zhang, X., Wang, J., Zhou, Z., & Lin, C. (2019). Treatment of a patient with total urinary calculi: a case report. Translational Andrology and Urology, 8(6), 764.
Mahboubi, M. (2020). Quercus fruit hulls and galls and female genital disorders. Clinical Phytoscience, 6(1), 1-6.
Pichetshote, N., & Pimentel, M. (2019). An approach to the patient with chronic undiagnosed abdominal pain. American Journal of Gastroenterology, 114(5), 726-732.
Queiroz, D. M., Valenzuela, R. G. V., Marinho, A. W. G. B., Santos, S. S. B. D., Silva, D. O. D., Dias, M. D. S., & Cruz, L. D. O. (2020). Atypical clinical presentation of distal renal tubular acidosis: a case report registered in Amazonas, Brazil. Brazilian Journal of Nephrology, (AHEAD). Dysuria and Lower Abdominal Cramping