CCS- Acute Cystitis
harry206 - 05-10-09 16:53

Location: Office
Presenting complaint: A 25-year old white female presents with burning micturition.
Vitals: Pulse: 80/min, B.P: 130/80 mm Hg, Temp:990F, R.R:14/min, Height: 67 inches
(167.5 cm), Weight: 79 Kg (173.8 lbs).
HPI: A 25-year-old personal secretary at a local office presents with the complaints of
three days of burning micturition, urgency, and frequency. She had to pass urine 10
times yesterday. She also complains of suprapubic discomfort. There is no vaginal
discharge, fever, hematuria, or flank pain. She has no previous history of STD or UTI.
ROS is unremarkable. She has no known allergies. Medications: None. SH: She is a
personal secretary at a local office. She has been married for five years and has no
children. She has been smoking 10 cigarettes for the last seven years and drinks
alcohol on weekends. She is sexually active in a monogamous relation with her
husband. They have not been practicing contraception. Her last menstrual period was 3
weeks ago.
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PHYSICAL EXAMINATION:
General Appearance
Abdominal
Genital/Pelvic exam

FINDINGS:
Suprapubic tenderness present
Normal Pelvic examination
No Urethral and vaginal discharge
No costovertebral angle tenderness
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ORDER:
UA, stat
B HCG urine, qualitative, stat
PAP smear, Routine
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OBTAIN RESULT FOR TEST:
(WITH NEXT AVAILABLE RESULT)
RESULT:
Serum pregnancy test is positive
Urine appearance Turbid/ yellow
pH 5.6 (normal 4.1-8.0)
Specific Gravity 1.016 (normal 1.003-1.030)
Bilirubin Negative
Ketones Negative
Glucose Negative
Blood Negative
Leukocyte
Esterase Positive
Nitrite Positive
Protein Negative

Microscopic Analysis:
Epithelial cells -
Bacteria 20-30/hpf
RBC/WBC Casts -
WBC 30-40/hpf
RBC 3/hpf
Crystals -
Mucus -
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ORDER:
TMP-SMZ, Oral, Continuous (for 7 days)
COUNSEL patient, Routine --->will advance Clock 5 min
Folic Acid therapy, Oral, Continous
Iron Gluconate, Oral, Continous
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CHANGE PT LOCATION --->Home
ORDER REVIEW (Pap smear, TMP SMZ)
SCHEDULE APPOINTMENT (15th day from today)
CONFIRM MOVE
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CASE ENDS IN 5 MIN REAL TIME
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WRITE NEW ORDER
Smoking cessation, Routine, Now
Limit alcohol, Routine, Now
Regular exercise,Routine, Now
Avoid illegal use, Routine, Now
Seat belt, Routine, Now
Medication compliance
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EXIT CASE
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DIAGNOSIS:
Uncomplicated acute cystitis and Pregnancy