Discussion: Burning sensation when urinate

CC: “I am having burning sensation when urinate”.

HPI: 52 y/o female patient white, Hispanic, refers come today because she has Burning when urinating, pain at the level of the pubis and on the sides, frequent urination at night, feeling chills, and yesterday gave him a little fever, also reported little appetite. He says that the urine is deep yellow, denies menstrual or vaginal problems, and does not suffer from any chronic disease.

REVIEW OF SYSTEMS

CONSTITUTIONAL

Patient denies having weight change, fatigue, weakness, refers fever, chills and urinary symptoms.

HEAD: Patient denies having trauma, nausea, or headaches.

EYES: Patient denies having blurred vision, tearing or itching.

EARS: Patient denies having hearing loss, tinnitus, vertigo, discharge or earache.

NOSE: Patient denies having rhinorrhea, stuffiness, sneezing, itching, allergy or epistaxis.

THROAT: Patient denies sore throat, dysphagia, dysphonia or halitosis.

CARDIAC: Patient denies any chest pain, shortness of breath, murmurs, palpitations or diaphoresis.

RESPIRATORY: Patient denies any chest pain, shortness of breath, wheezing, cough, no chest congestion.

VASCULAR: Patient denies any leg edema, leg pain, varicose veins or skin color change.

ORDER CUSTOM, PLAGIARISM-FREE PAPER

SKIN: Patient denies nail change, itching, rashes, sores, lumps or moles.

GASTROINTESTINAL: Constipation: No, diarrhea No, Nausea No. pain no.

GENITOURINARY: Patient refers increase in frequency, hesitancy, urgency, dysuria, nocturia and low and costal back pain.

MUSCULOSKELETAL: Patient denies any muscle weakness, pain, joint stiffness, and full range of motion, instability, swelling or any redness.

NEUROLOGIC: Patient denies any dizziness, numbness, tingling, tremors, weakness, fainting, seizures or any memory loss.

HEMATOLOGIC: Patient denies anemia, easily brusing or bleeding, petechiae, purpura or transfusions.

ENDOCRINE: Patient denies heat/cold intolerance, excessive sweating, or thirst.

PSYCHIATRIC: Patient denies any mood swings, tension, fear or anxiety.

Vitals signs:

Blood Pressure: 138/80 mmhg; Discussion: Burning sensation when urinate

Pulse: 82 ppm;

Respiration: 16 x min.

Temperature 98.1 F;

Height: 5.9 Weight: 182 BMI: 26.9

Pain scale 2/10.

PHYSICAL EXAM

General Appearance

Patient appears well developed, well nourished, and well groomed. Normal habitus. Refers urinary symptoms. No deformities noted.

HEENT: Pupils are equally reactive and responsive to light and accommodation (PERRLA). Extraocular muscles intact (EOMI). Patient exhibits pink conjunctiva, clear oropharynx. Normal exterior ear canal, bilateral TM pearly gray. Hearing and vision are within normal limits. Tongue protrudes midline.

Neck: Neck is supple with full range of motion. No carotid bruits. No JVD, Adenopathy or Goiter. Thyroid appears normal w/o masses.

Heart / Cardiovascular: Examination of the heart is normal. Regular Rate & Rhythm (RRR). Normal S1 and S2. No murmurs, gallops or rubs. No intensity or PMI. A2 = P2.

Lungs / Respiratory: Clear to Auscultation (CTA) bilaterally. Normal breath sounds, percussion, and respiratory effort. No Wheezing or Rhonchi. No friction rubs.

Abdomen: Abdomen non-distended. Soft. No tenderness noted. Bowel sounds present on all quadrant. No masses. No Hepatosplenomegaly. No Hernia. No gradient and no rigidity. Suprapubic pain 2/10.

Genitourinary: Presence of dysuria; urgency frequency; suprapubic pain; costovertebral angle pain; nocturnal;

Extremities: No clubbing, cyanosis, or edema. Full Range of Motion (ROM). No swelling.

Musculoskeletal: Upper and Lower Extremities appear symmetrical. No obvious musculoskeletal deformities noted.

Skin: Skin is grossly intact. No specific abnormalities have been noted.

Neurological: Patient is alert and oriented to Time, Place, and Person (AO x 3). CN – II, XII grossly intact. Motor strength 5/5 throughout. DTR + 2 throughout, with down going toes. Sensory intact. Gait within normal limits.

Lymphatic: No cervical, axillary, or inguinal adenopathy noted.

Psychiatry: Anxiety noted. No suicidal ideation, sleep well, not mood disorder.

Assessment:

ICD 10: N39.0, Urinary tract infection (UTI) is an inflammatory reaction of the urinary tract epithelium in response to pathogenic microorganisms, most commonly bacteria. [1] The diagnosis is confirmed when urine obtained from a symptomatic male demonstrates growth of a significant amount (≥≥10^2 colony-forming units [CFU]/mL) of one organism, or a predominance of one organism, when cultured

DDx:

ICD 10: N10; Pyelonephritis: Often a complication of UTI, but can occur without history of UTI. May be indicated by costovertebral angle pain with tenderness on examination.

ICD 10: N21.9 Urinary tract stones: Urinary tract stones may result in damage of the urinary epithelium and consequently dysuria; however, they also typically cause pain.

ICD 10: A56.01; Chlamydia urethritis: New or multiple sexual partners implies risk. Frequency and urgency of urination as well as fever are often absent. Occurs more commonly in young men.

Assessment/Plan:

Patient Education:

Psychotherapy

The purpose of therapy is to temporarily eliminate bacteriuria, because the presence of nonsterile urine during urologic procedures increases the risk of bacteremia and sepsis.

Medications:

Ciprofloxacin: 500 mg orally twice daily for 3 days

Acetaminophen 325 mg 1 tab PO each 8 hrs. If pain are present.

Lifestyle and home remedies

Urinary tract infections can be painful, but you can take steps to ease your discomfort until antibiotics treat the infection. Follow these tips:

Drink plenty of water. Water helps to dilute your urine and flush out bacteria. Discussion: Burning sensation when urinate

Avoid drinks that may irritate your bladder. Avoid coffee, alcohol, and soft drinks containing citrus juices or caffeine until your infection has cleared. They can irritate your bladder and tend to aggravate your frequent or urgent need to urinate.

Use a heating pad. Apply a warm, but not hot, heating pad to your abdomen to minimize bladder pressure or discomfort.

Referral: No.

F/U: 2 weeks.

References:

1-Stensballe J, Tvede M, Looms D, et al. Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients: a randomized trial. Ann Intern Med. 2007 Sep 4; 147 (5):285-93.

2-Pickard R, Lam T, MacLennan G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet. 2012 Dec 1; 380 (9857):1927-35.

Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012 Oct 17; (10):CD001321