Internal Medicine For 14-18 Year Old Females Pre-College Phy

Internal Medicine 14 18 Year Old Female For Pre College Physicalwhat

Internal Medicine 14: 18-year-old female for pre-college physical. What is (are) the most likely diagnosis (diagnoses)? What were the clinical findings that confirmed the diagnosis (diagnoses)? The most likely diagnosis is cystitis. Patient complains of urinary frequency, dysuria, bladder pain and hematuria. On physical exam there is mild midline suprapubic tenderness. Her urine dipstick was positive for leukocyte esterase, nitrites, and hemoglobin. The next diagnosis is chlamydia. Women with chlamydia usually present with symptoms such as vaginal discharge, postcoital or intermenstrual bleeding, lower abdominal pain, pelvic pain, painful intercourse, and dysuria. The patient in the case study presented with suprapubic pain, hematuria, and dysuria.

The test of choice is nucleic acid amplification testing (NAAT) for N. gonorrhea and C. trachomatis. NAAT is a sensitive and specific assay and has replaced culture methods. It can be used on urine specimens as well. How is it (are they) treated according to the most recent clinical guidelines? Cystitis is treated with nitrofurantoin 100 mg orally twice daily for 5 days (IDSA/ESCMID guidelines). Chlamydia is treated with doxycycline 100 mg orally twice daily for 7 days (CDC 2021). The World Health Organization (WHO) recommends azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days for uncomplicated chlamydial infections.

A plan of care for the patient includes patient education and additional tests. In complicated cystitis, imaging such as a CT scan or renal ultrasound is recommended to rule out nephrolithiasis or obstruction prior to urologic evaluation. Urologic evaluation, including cystoscopy, is indicated if hematuria persists after eradication of infection. Symptomatic relief measures include hot sitz baths or urinary analgesics such as phenazopyridine 200 mg three times daily. Patients should be advised to drink plenty of fluids and to completely empty their bladder frequently to reduce infection risk. Patients should void before and after intercourse, with a postcoital single dose of antibiotics if indicated. For chlamydia, screening for reinfection is recommended three months post-treatment, even if partners were treated. Patients should return if symptoms persist or recur, abstain from sexual activity until symptoms resolve and partners are treated, and be tested for other STDs including HIV and syphilis. Providing partner treatment directly via expedited partner therapy (EPT) is also recommended.

Paper For Above instruction

This case presents a young female patient undergoing a pre-college physical who exhibits symptoms indicative of urinary tract infection (UTI) and sexually transmitted infection (STI). The primary diagnoses considered are cystitis, a common bladder infection, and chlamydia, a prevalent STI. This comprehensive evaluation reviews the clinical findings, diagnostic approaches, and current treatment guidelines pertinent to these conditions, along with an integrated care plan emphasizing patient education, follow-up, and preventive strategies.

Introduction

Urinary tract infections and sexually transmitted infections are frequent health concerns among adolescent females, often presenting with overlapping symptoms such as dysuria, urinary frequency, and suprapubic pain. Accurate diagnosis and prompt management are essential to prevent complications, including renal involvement or chronic pelvic pain. Understanding the clinical presentation, diagnostic modalities, and evidence-based treatment protocols is vital for healthcare providers managing young women in pre-college health evaluations.

Clinical Presentation and Diagnosis

The patient's symptoms of urinary frequency, dysuria, bladder pain, and hematuria strongly suggest cystitis, particularly in the context of a young female with no mention of risk factors for complicated urinary tract issues. Physical examination findings such as mild midline suprapubic tenderness support the suspicion of bladder inflammation. Urinalysis revealing leukocyte esterase, nitrites, and hemoglobin confirms the likelihood of an infectious process involving the urinary tract. Notably, nitrites indicate bacterial reduction of nitrates, predominantly caused by gram-negative organisms like Escherichia coli, which are common culprits in cystitis.

Furthermore, considering the patient's age and sexual activity, chlamydia and other sexually transmitted infections must be considered. Chlamydia trachomatis is often asymptomatic but can present with symptoms like vaginal discharge, postcoital bleeding, or pelvic discomfort. The presentation of suprapubic pain, hematuria, and dysuria could also be attributed to chlamydial urethritis or cervicitis. Therefore, nucleic acid amplification testing (NAAT) using urine specimens is recommended for detecting N. gonorrhoeae and C. trachomatis with high sensitivity and specificity, replacing traditional culture methods.

Management of Cystitis and Chlamydia

Current guidelines recommend specific antimicrobial therapies based on the patient's diagnosis. For uncomplicated cystitis, the Infectious Diseases Society of America (IDSA) and European Society for Microbiology and Infectious Diseases (ESCMID) endorse nitrofurantoin 100 mg orally twice daily for five days as a first-line empiric therapy. Nitrofurantoin's efficacy stems from its high urinary concentration and activity against common uropathogens.

For confirmed or suspected chlamydial infections, the CDC 2021 guidelines advocate doxycycline 100 mg orally twice daily for seven days as the first-line treatment. An alternative is single-dose azithromycin 1 g orally, which offers a convenient option, especially for patients with adherence concerns. The WHO recommends doxycycline or azithromycin as effective agents for uncomplicated chlamydial infections worldwide.

Plan of Care

The comprehensive management approach includes pharmacological treatment, patient education, diagnostic follow-up, and preventive strategies to reduce recurrence and transmission. The initial step involves administering the prescribed antibiotics while providing detailed education about medication adherence, potential side effects, and the importance of abstaining from sexual activity until treatment completion.

Additional diagnostic work-up includes imaging studies such as renal ultrasound or computed tomography (CT) scan in cases of complicated cystitis or persistent hematuria to exclude nephrolithiasis, renal masses, or obstruction. If hematuria persists after infection eradication, referral for urologic evaluation, including cystoscopy, is indicated to investigate underlying pathology.

Symptomatic relief is achieved through supportive measures such as warm sitz baths and urinary analgesics like phenazopyridine 200 mg three times daily, which alleviates bladder discomfort but does not treat infection. Encouraging adequate fluid intake and frequent voiding reduces bacterial colonization and prevents recurrence.

For chlamydia, screening for reinfection at three months post-treatment is crucial, as reinfection rates remain high in sexually active young women. Counseling on safe sexual practices, consistent condom use, and partner notification is essential. Providing partner therapy through expedited partner therapy (EPT) is supported by evidence to reduce reinfection rates and curb transmission.

Prevention and Education

Preventive health measures include routine sexual health education, promoting condom use, and encouraging regular STI screening. The young woman should be educated about recognizing symptoms of recurrent infections and the importance of follow-up testing. Reinforcing the need for abstinence until treatment completion and partner treatment reduces the likelihood of reinfection and further complications.

Conclusion

This case underscores the importance of a thorough clinical assessment, appropriate diagnostics, and adherence to current guidelines in managing urinary and sexually transmitted infections among adolescents. A patient-centered approach focusing on education, preventive strategies, and timely intervention can optimize health outcomes and reduce the burden of these common conditions in young women.

References

  • Chumley, H. S., & Usatine, R. P. (2019). Gonococcal and chlamydia urethritis. In R. P. Usatine, M. A. Smith, E. J. Bernstein, & H. S. Chumley (Eds.), The Color Atlas and Synopsis of Family Medicine (3rd ed.). McGraw Hill.
  • DynaMed. (2018). Chlamydia genital infection. Retrieved from https://www.dynamed.com
  • IDsA/ESCMID. (2018). Uncomplicated urinary tract infection (Pyelonephritis and Cystitis). Retrieved from https://www.idsociety.org
  • Kovach, R. A. (2020). Internal Medicine 14: 18-year-old female for pre-college physical. Retrieved from https://www.internalmedicinejournal.org
  • Papadakis, M. A., McPhee, S. J., & Bernstein, J. (2021). Cystitis, acute (urinary tract infection). In Quick Medical Diagnosis & Treatment (2021). McGraw Hill.
  • Centers for Disease Control and Prevention (CDC). (2021). Sexually transmitted infections treatment guidelines. https://www.cdc.gov/std/tg2021
  • World Health Organization (WHO). (2018). Guidelines for the management of sexually transmitted infections. WHO Publications.
  • Petersen, M. R., & Dunford, S. (2019). Epidemiology of urinary tract infections in young women. Journal of Urology, 202(4), 765-772.
  • Scholes, D., et al. (2000). Prevention of urinary tract infection in adult women: a randomized trial. JAMA, 283(19), 2553-2558.
  • Hooton, T. M. (2012). Uncomplicated urinary tract infection. New England Journal of Medicine, 366(11), 1028-1037.

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