A 25-year-old woman complains of a 2-day history of dysuria, urgency, and urinary frequency. She denies the use of any medications and has no significant past medical history.
On examination, her blood pressure (BP) is 100/70 mm Hg, heart rate (HR) is 90 beats per minute, and temperature is 98°F (36.6°C). The thyroid is normal on palpation. The heart and lung examinations are normal. She does not have back tenderness. The abdomen is non tender and without masses. The pelvic examination reveals normal female genitalia. There is no adnexal tenderness or masses.
1. What is the most likely diagnosis?
2. What is the next step in the diagnosis?
3. What is the most likely etiology of the condition?
Answers And Discussion:
1. What is the most likely diagnosis?
Answer: Simple cystitis (bladder infection).
A 2-day history of urinary urgency, frequency, and dysuria, all are very typical symptoms of a lower urinary tract infection. Because the patient does not have any fever or flank tenderness, she most likely has a bladder infection or cystitis.
2. What is the next step in the diagnosis?
Answer: Next step in the diagnosis:should include a urinalysis and/or urine culture.
3. What is the most likely etiology of the condition?
Answer: Since E coli is the most common etiologic agent, the antibiotic treatment should be aimed at this organism. Current evidence points to trimethoprim/sulfa for a 3-day course as the best agent for uncomplicated cystitis unless bacteriology patterns in the community point to resistance; in that case, a quinolone such as ciprofloxacin twice daily for 3 days is effective.
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