Final answer:
A 25-year-old female with dysuria, urgency, and burning is likely facing a urinary tract infection, with the potential for a sexually transmitted infection. Urgent care includes a physical exam, diagnostic tests such as urinalysis, and empirical antibiotic therapy. Her treatment may be adjusted pending lab results.
Step-by-step explanation:
The case presents a 25-year-old female with symptoms including dysuria, urgency, and burning, alongside suprapubic tenderness to palpation (tenderness upon touching the area above the pubic bone). She has no fever, no vaginal discharge, and no flank pain, which helps narrow down the differential diagnosis. Given that she is sexually active and not using contraception, a sexually transmitted infection (STI) such as chlamydia or gonorrhea could be a possibility, as could a urinary tract infection (UTI). Pelvic inflammatory disease (PID) is less likely in the absence of vaginal discharge or other reproductive organ symptoms.
Emergency Orders
Stabilize the patient and ensure hemodynamic stability, which, in this case, seems fine as the patient is afebrile and hemodynamically stable.
Physical Exam
Assess the suprapubic area, examine for costovertebral angle tenderness (which could indicate a kidney infection), and perform a pelvic examination to rule out PID or other gynecological issues.
Diagnostic Tests
Order a urinalysis, urine culture, and possibly STI screening tests like NAAT (nucleic acid amplification test) for chlamydia and gonorrhea. A pregnancy test should also be considered due to her LMP being 24 days ago and lack of contraception.
Therapy
Start empirical treatment for UTI with an appropriate antibiotic while awaiting test results, often a course of trimethoprim-sulfamethoxazole or nitrofurantoin is prescribed. Educate the patient on the importance of completing the full course of antibiotics and possible side effects.
Location
Initial care in an outpatient setting like a primary care office or urgent care is appropriate unless symptoms worsen or emergency signs develop.
Final Order
Follow up after diagnostic test results to adjust antibiotic therapy if needed based on culture and sensitivity results.
Dx
A presumptive diagnosis of UTI with the potential for STI based on the patient's sexual history and current symptoms.