History

Name: K.J.

Sex: Female

Age: 39 years

Date: March 15, 2024

Location: Dr. Devicka Persaud

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Public transportation

CC:

“My pee smells bad” x 7 days.

HPI:

39 year old female with PMHx of hyperlipidemia presents with complaints of a foul, fishy odor in her urine x7 days. Pt also admits to mild dysuria towards the end of urination x7 days. The pain is a burning pain that is 5/10 in severity. Pt states that she recently started taking atorvastatin and she believes that may be causing these symptoms. Pt has had UTIs in the past which all present with the same symptoms. Pt admits to drinking very little water (some days drinking no water at all) and holding in urine for long periods of time. Pt says she is sexually active with one male partner, most recently 10 days ago. She denies use of any contraception. 

Denies fever, abdominal pain, nausea, vomiting, diarrhea, urinary frequency, urgency, flank pain and vaginal discharge.

PMHx:

• Hyperlipidemia x1 month, started on meds this month
• No known surgeries or hospitalizations
• UTD on all vaccines

Medications:

• Atorvastatin 40 mg oral tablet for hyperlipidemia
• Denies herbal supplement use.

Past surgical history:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family history:

• Mother: Alive age 66, endometrial cancer and HTN
• Father: Alive age 69, HTN and DM
• No children

Social history:

• Smoking: Denies
• Alcohol: Socially
• Illicit drug use: Denies past or current use
• Marital History: Single
• Language: English
• Occupational History: MTA worker
• Travel: No recent travel
• Home situation: Lives in an apartment in Queens on her own
• Sleep: Endorses adequate sleep
• Exercise: Tries to exercise by walking to work
• Diet: Reports carb heavy diet with protein and vegetables
• Caffeine: Denies caffeine use 

Review of Systems:

• General– Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails– Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT– Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
• Neck– Denies localized swelling/lumps, stiffness/decreased ROM
• Breast– Denies lumps, nipple discharge, or pain.
• Pulmonary– Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular– Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal- Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary– Admits to dysuria and malodorous urine. Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge.
• Menstrual/Obstetrical- G0P0000, LMP 03/05/2024; sexually active with one male partner
• Musculoskeletal– Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system- Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular– Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic– Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine– Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric– Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in no apparent discomfort. Appears stated age of 39. Neatly groomed, alert and oriented x3.

Vitals:

• BP: 128/80 mm Hg
• R: 17/min, regular rate and rhythm, unlabored
• P: 102 beats per minute, regular rate, rhythm and amplitude 
• T: 97 degrees F (temporal)
• Height: 60 inches Weight: 219 lbs BMI: 42.77

Skin/Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Hair: No balding with average texture. No alopecia, seborrhea, or lice on exam.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Nose/Sinuses:

• Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.
• Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses. 

Mouth/Pharynx:

• Teeth: Good dentition. No obvious dental caries noted.
• Tongue: Pink and well papillated. No masses, lesions or deviation. Mild fasciculation on exam. 
• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Tonsils present with no injection or exudate. Grade 1 tonsils. Uvula midline, pink with no edema or lesions.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. Supple and non-tender to palpation. FROM, no stridor noted. 2+ carotid pulses, no bruits or thrills noted bilaterally. No cervical adenopathy.
• Thyroid: Non-tender to palpation. No masses, thyromegaly, or bruits noted.

Thorax/Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Mild tenderness to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Pelvic:

• Genitalia: external genitalia without erythema or lesions. Vaginal mucosa Pink without inflammation, erythema or discharge. Cervix multiparous, pink and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Neurologic:

• Cranial Nerves: CN I- XII are intact
• Mental status exam: Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgment, cognition, memory and attention intact.
• Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally. No clonus. Plantar reflex is downward bilaterally.
• Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact. 
• Motor: Good muscle tone. Strength is 5/5 bilaterally at the deltoid, biceps, triceps, quadriceps, and hamstrings. 
• Cerebellar: Finger-to-nose and heel-to-shin test normal bilaterally. Balances with eyes closed (Romberg). Rapid alternating movements are normal. Gait is steady with a normal base. Coordination is intact as measured by heel walk and toe walk. 

Peripheral vascular system:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric. 

Musculoskeletal:

• No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion of all upper and lower extremities bilaterally. 

Differential diagnosis:

• UTI (cystitis)
  • Being that this pt has had these symptoms previously and has been diagnosed with a UTI, it is probable that she has another UTI. She presents with dysuria and foul smelling urine, common symptoms of UTIs. She does not have fever, flank pain or systemic symptoms which rules out pyelonephritis. Additionally, her history of drinking very little fluids puts her at greater risk for developing UTIs. Although uncommon, atorvastatin does present as a risk factor for developing UTI.
• STD (chlamydia, gonorrhea)
  • This pt admits to having sexual intercourse without any form of protection. This presents a risk for developing an STD. These are often asymptomatic but may present with dysuria and vaginal discharge. This pt has dysuria, consistent with this ddx. However, being that she has previously had UTIs with these symptoms, her diagnosis is more likely to be a UTI. 
• Bacterial vaginosis
  • This pt presents with fishy smelling urine. BV presents with a thick, white/gray vaginal discharge that has a fishy odor. Although this pt has the malodorous urine, I still thought this was a good ddx being that the smell is described in the same way. Additionally, a risk factor for BV is having unprotected sexual intercourse, which is consistent with this patient’s history. However, this is least likely being that she denies any vaginal discharge. 

Labs:

• Urinalysis: large amounts of leukocyte esterase, trace blood

Assessment:

• 39 year old female with PMHx of hyperlipidemia presents with complaints of a foul, fishy odor in her urine x7 days. Pt also has associated dysuria. On exam, pt has mild tenderness throughout all 4 quadrants of her abdomen. All other parts of the exam are within normal limits. Labs are significant for large amounts of leukocyte esterase and trace blood on urinalysis. This is most consistent with a diagnosis of cystitis.

Diagnosis:

• UTI

Plan:

• UTI
  • Urine culture
  • Nitrofurantoin 100 mg BID x7 days (taken with food)
  • Pt education
    • Increase water intake
    • Avoid tight fitting clothes
    • Urinate frequently, especially after intercourse
    • Avoid diaphragms, spermicide and drinks that irritate the bladder (coffee, soda, alcohol)
• Dyslipidemia
  • Continue atorvastatin 40 mg