[##]-year-old female with [dysuria/hematuria/flank pain] with history
and exam consistent with likely urinary tract infection (UTI).
Initial consideration in this patient included urinary tract infection
(UTI), pyelonephritis, vaginitis, kidney stone, and sexually transmitted
infections (STI) among others.
The patient was noted to have [WBCs/leukocyte
esterase/nitrites/hematuria] on urinalysis consistent with a UTI. No evidence of significant costovertebral
angle (CVA) tenderness, fever, or other systemic symptoms suggestive of
pyelonephritis or urosepsis noted at this time.
Doubt ureteral stone in patient without significant CVA tenderness,
flank pain, or other findings suggestive or ureteral colic. Doubt STI at this time in patient without
significant risk factors. Negative
pregnancy test obtained in the ED making ectopic or other pregnancy-related
complications unlikely.
We discussed return precautions, specifically for evidence of worsening
infection, treatment with antibiotics [and bladder anesthetic/pyridium], and follow up
with primary care doctor within 1-2 weeks as needed for further evaluation, and
the patient demonstrated understanding and agreement with this plan.
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