NRNP 6531 Week 5 Dysuria Visit Note Example

Focused Visit Note: Four Days of Dysuria in a 23-Year-Old Woman, With a Sexual History That Changes the Differential

Student Name

College of Nursing, Walden University

NRNP 6531: Primary Care of Adults Across the Lifespan

Instructor Name

Month Day, Year

Focused Visit Note: Four Days of Dysuria in a 23-Year-Old Woman, With a Sexual History That Changes the Differential

Subjective

Chief complaint: burning with urination for four days.

History of present illness: T.R. is a 23-year-old graduate student, a composite patient built for this note. Dysuria began four days ago and has been steady rather than worsening. She reports mild frequency and urgency but not the constant urge she remembers from a bladder infection two years ago. She has noticed a mild change in vaginal discharge over the past week, slightly more than usual and without odor. She has had no visible blood in her urine. She denies flank or back pain, fever, chills, nausea, and vomiting. She denies vulvar itching, sores, or pelvic pain with intercourse.

Sexual history, taken with the five Ps and without judgment (Workowski et al., 2021): Partners: two male partners in the past three months, one new within the past month. Practices: vaginal and oral sex. Protection: condoms used inconsistently with the new partner; she uses an etonogestrel implant for contraception. Past infections: none diagnosed; last STI testing more than a year ago. Pregnancy intention: does not want pregnancy now; last menstrual period two weeks ago and normal.

Past medical history: one uncomplicated urinary tract infection two years ago. Medications: etonogestrel implant. Allergies: none. Social: does not smoke, drinks alcohol socially.

Review of systems: no fever, rash, joint pain, eye redness, or sore throat, which would suggest disseminated or extragenital gonococcal infection; no intermenstrual or postcoital bleeding; no abdominal pain; no recent antibiotic use, which matters because recent antibiotics raise the likelihood of candidiasis; no new soaps, douches, or spermicides that could cause chemical irritation of the urethra.

Objective

Vital signs: temperature 98.4 F, heart rate 72, blood pressure 112/68. Abdomen: soft, mild suprapubic tenderness, no rebound or guarding. Costovertebral angle tenderness absent on both sides. Point-of-care urine: leukocyte esterase trace positive, nitrite negative, blood negative. Urine pregnancy test negative. A pelvic examination was offered and deferred at her preference after discussion; self-collected vaginal swabs were obtained for testing.

Assessment

The history moves sexually transmitted urethritis up the list, even though dysuria in a young woman is often assumed to be a bladder infection. Frequency and urgency are milder than in her previous cystitis, the nitrite is negative, the leukocyte esterase is only trace, and she has a new partner, inconsistent condom use, and a change in discharge.

1. Urethritis or cervicitis from Chlamydia trachomatis or Neisseria gonorrhoeae. For: new partner, inconsistent condoms, age under 25, discharge change, pyuria with a negative nitrite. Against: no pelvic pain or abnormal bleeding. Chlamydia is often asymptomatic or mildly symptomatic in women, and the guideline advises routine screening of every sexually active woman younger than 25 (Workowski et al., 2021).

2. Acute uncomplicated cystitis. For: dysuria, frequency, urgency, suprapubic tenderness, prior cystitis. Against: milder urinary symptoms, negative nitrite, and only trace leukocyte esterase, although a negative nitrite does not exclude cystitis.

3. Trichomoniasis. For: discharge change and a new partner. Against: no odor, itching, or irritation.

4. Vulvovaginal candidiasis or bacterial vaginosis. For: discharge change. Against: no itching and no odor. Pyelonephritis is not on this list because she has no fever, flank pain, or costovertebral angle tenderness, which were specifically assessed.

Plan

Testing paired with each diagnosis: nucleic acid amplification testing for chlamydia and gonorrhea from the self-collected vaginal swab, the preferred specimen in women; trichomonas nucleic acid amplification testing on the same swab; urine culture, because the dipstick is equivocal and a culture will settle cystitis; and HIV and syphilis screening, offered as recommended for people being tested for other sexually transmitted infections, which she accepted (Workowski et al., 2021).

Treatment today: because she has symptoms, a new partner, and pyuria, and because follow-up cannot be guaranteed before results return, she is treated presumptively for chlamydia with doxycycline 100 mg taken twice a day for one week. Gonorrhea treatment is deferred to results, since she has no mucopurulent cervicitis on history and ceftriaxone requires an injection; she understands she will be called and treated promptly if positive. If the urine culture grows a uropathogen, nitrofurantoin will be prescribed, a first-line agent for uncomplicated cystitis (Gupta et al., 2011).

Counseling: abstain from sex until seven days after starting treatment and until partners are treated; partner notification discussed, including expedited partner therapy if chlamydia is confirmed, which her state permits. Condom use discussed as protection against infection, separate from her effective contraception. Doxycycline taken with water and food, upright, and not with dairy or iron at the same time; sun protection advised.

Follow-up: results by phone within 72 hours. Return if symptoms persist after treatment, or sooner with fever, flank pain, pelvic pain, or vomiting. Retesting for chlamydia or gonorrhea is recommended about three months after treatment if positive, because reinfection is common (Workowski et al., 2021; Dains et al., 2020).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103-e120. https://doi.org/10.1093/cid/ciq257

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports, 70(4), 1-187. https://doi.org/10.15585/mmwr.rr7004a1