PATHOPHYSIOLOGY NR 507 WEEK 4 TD 1

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Week 4: Alterations in Renal Function - Discussion Part One Loading... Discussion This week's graded topics relate to the following Course Outcomes (COs). 1 2 3 4 5 6 7 Analyze pathophysiologic mec... hanisms associated with selected disease states. (PO 1) Differentiate the epidemiology, etiology, developmental considerations, pathogenesis, and clinical and laboratory manifestations of specific disease processes. (PO 1) Examine the way in which homeostatic, adaptive, and compensatory physiological mechanisms can be supported and/or altered through specific therapeutic interventions. (PO 1, 7) Distinguish risk factors associated with selected disease states. (PO 1) Describe outcomes of disruptive or alterations in specific physiologic processes. (PO 1) Distinguish risk factors associated with selected disease states. (PO 1) Explore age-specific and developmental alterations in physiologic and disease states. (PO 1, 4) Discussion Part One (graded) Mrs. Orndorf is a 28-year-old woman married for 3 years who has just returned from an outdoor camping trip with her husband, with symptoms of dysuria with a burning sensation, urgency to urinate, and frequent urination. She said, “I have had similar symptoms three times over the last 2 years. Pubic and low back discomfort awoke me two nights ago and that is why I am here.” On physical examination, her temperature was 98.6° F, blood pressure was 114/64 mm Hg, pulse was 68 beats per minute, and the respiratory rate was 12 breaths per minute. Other than a tender abdominal pelvic area, the examination was unremarkable. • What is your list of differential diagnoses in this case and explain how each of these fits with the case patient as described above. Be sure to list at least four (4) pertinent differential diagnoses. Indicate which of these you would select as the most likely diagnosis and explain why. • According to the first item in your differential, what are the risk factors for this disorder? • What are some treatments for this disorder? Responses Sarah Boulware Part One Dr. Brown and Class, 5/22/2016 11:34:18 AM1.Primary Diagnosis: Acute Cystitis secondary to Urinary Tract Infection (UTI) According to DiVito (2014) a UTI is caused by the presence and multiplication of bacteria in the urinary tract, with associated tissue invasions. Urine is stored in the bladder and is considered sterile. UTIs develop when part of the urinary system becomes colonized with pathogenic bacteria. The bacterium most likely enters the urinary system through the urethra. Escherichia coli, usually found in the colon, is the most common cause of UTIs in women. Haddock (2015) found the most common symptoms of a UTI include dysuria, frequency, urgency, polyuria, and suprapubic tenderness. If there is vaginal discharge it is unlikely that it is related to UTI. Three or more of the classic symptoms of a UTI indicate a 90% chance that it there is a bacterial infection. Symptoms of an upper UTI include the same symptoms as a lower UTI as well as a high fever, nausea or vomiting, shaking or chills, confusion, and pain in the lower back or on one side. It is important to recognize evidence of an upper UTI because of the risk of pyelonephritis. There are several risk factors for UTIs. The female urethra is considered to be shorter in length along with a close proximity to the rectum. Bacteria from fecal matter, sexual intercourse or poor personal hygiene can easily travel along the perineum into the urethra and up into the bladder causing a UTI. Other contributing factors for UTIs include an obstruction the urinary system (bladder stones), incomplete bladder emptying, a weakened immune system, sexual intercourse, the presence of a foreign body (urinary catheter), and hormonal changes in women (Divito, 2014). The two major risk factors for UTIs in young women are recent sexual intercourse and a history of recurrent UTIs (Litherland, 2011). Mrs. Orndorf is exhibiting classic symptoms a UTI that include, burning sensation, urgency to urinate, and frequent urination. She also stated she has had similar symptoms three times in the past two years, which indicates that she could possibly have recurrent UTIs. She is at a high risk for UTIs because she is a woman, possibly sexually active with her husband (more information is needed), and has been camping, which could have compromised sanitary conditions, increasing the risk for bacterial infection. She presented with suprapubic pain and low back discomfort which can occur with a UTI. Treatment for a UTI includes antibiotic therapy. For an uncomplicated UTI a short 3-day dose of trimethoprim or nitrofurantoin are the common choices. Short courses have been shown to be as effective as longer courses. Broader spectrum antibiotics, like ciprofloxacin, are indicated for upper UTIs. A shorter course of antibiotics will reduce the side effects without the development of antimicrobial resistance. Cranberry products are have been a controversial treatment in reducing the frequency of recurrent UTIs. Cranberries are an alkalysing agent that has been thought to contain an active ingredient that prevents the adherence of bacteria, specifically E. coli, from adhering to the bladder wall. Drinking more fluids was found to have no evidence base. Women are recommended to use over the counter analgesics, such as ibuprofen, to relive pain, and begin a short course of appropriate antibiotic therapy (Haddock, 2015). 2. Pyelonephritis Pyelonephritis is a lower urinary tract infection that has ascended to the pelvis of the kidney. Typical signs and symptoms include unilateral flank pain, hematuria, polyuria, offensive smelling urine, dysuria, urgency, tachycardia, tachypnea, and fever. Symptoms can vary from mild with a gradual onset to acute presentation of severe symptoms. Clinical signs and symptoms are often unreliable and inconsistent, therefore further diagnostic testing is needed. I am concerned about pyelonephritis because Mrs. Orndorf has had the symptoms of a UTI for at least two days, likely longer, but waited until her low back and suprapubic pain was so severe that it awoke her at night. Her UTI could have progressed to pyelonephritis with mild symptoms. She does not have a fever, flank pain, or tachycardia but this could be an early presentation of pyelonephritis (Bethel, 2012). 3.Urolithiasis According to Hochwind and Ashcroft (2012), kidney stones form when various minerals, such as calcium and phosphate, combine in the urine to form crystals. The crystals then precipitate to form a stone. It can be caused by low urine volume, alteration in urine pH balance, or when there is an overabundance of stone-forming mineral salts in the urine. Individuals with kidney stones typically present with renal colic symptoms, which is flank pain, nausea, vomiting, and hematuria. Renal colic is described as waves of severe pain that is felt in the flank and radiates toward the groin. It is not resolved upon changing positions and can last from 20 to 60 minutes. If the stone becomes obstructed at the urtero-vesical junction then symptoms are consistent with a urinary tract infection including dysuria, urinary frequency, and urinary urgency. Mrs. Orndorf has lower UTI symptoms. While she is having low back pain and suprapubic pain further diagnostic testing is needed to differentiate. 4. Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC) PBS/IC is defined as unpleasant sensations, such as pain, pressure and discomfort, related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes. Classic symptoms include bladder pain, urinary frequency, urgency, and nocturia. Pelvic pain, specifically suprapubic pain, is the key factor of diagnosing this condition. Pain is relieved upon voiding but quickly returns and may be aggravated by certain food or drink. Pain upon sexual intercourse is often common. Further assessment and diagnostic testing is needed to rule out a UTI and differentiate the diagnosis of PBS. If no bacteria are seen on Mrs. Orndorf’s urine culture it could possibly be PBS. She has the similar symptoms and they are recurrent at times. PBS is often misdiagnosed. In PBS the mucous layer of the bladder that protects it during urine storage is inadequately developed or defective. This leads to direct exposure of the bladder mucosa and submucosal nerve endings to urine, which triggers an inflammatory reaction in the bladder wall (Flander, 2013). References Bethel, J. Acute pyelonephritis: risk factors, diagnosis and treatment. Nursing Standard, 27(5), 51-56. Divito, M. (2014). Management of urinary tract infection (UTI) in the community. Journal of Community Nursing, 28(3), 18-26. Flander, N. (2013). Painful bladder syndrome and interstitial cystitis: treatment options. British Journal of Nursing, 22, 20-27. Haddock, G. (2015). Improving the management of urinary track infection. Nursing & Residential Care, 17(1), 22-25. Hochwind, C. & Ashcroft, K. (2012). Tamsulosin for ureteral stones – use in a pediatric population? Urologic Nursing, 32(2), 88-92. Litherland, A. (2011). Urinary tract infection: diabetic women’s strategies for prevention. British Journal of Nursing, 20(13), 791-796. Instructor Brown reply to Sarah Boulware 5/23/2016 4:58:10 PMRE: Part One If you review a burning sensation from a cellular level, what is the process? Sarah Boulware reply to Instructor Brown RE: Part One 5/25/2016 3:02:10 PM Dr. Brown, Michels and Sands (2015) found dysuria is burning, tingling, or stinging of the urethra and meatus that occurs when voiding. Acute cystitis is the most common cause although it can occur from a number of different issues. Sensory nerves are located just beneath the urothelium. Chemical irritations and inflammatory conditions can alter the mucosal barrier that protects these nerves causing them to be stimulated, which results in pain. When the submucosal barrier is damaged the nerve endings in the bladder wall are directly exposed to urine that contains irritating substances such as potassium. Inflammatory conditions are the most common cause of this. Chronic inflammation can lead to altered nerve sensitivity and persistent pain (Flander, 2013). Reference Flander, N. (2013). Painful bladder syndrome and interstitial cystitis: treatment options. British Journal of Nursing, 22, 20-27. Michels, T. & Sands, J. (2015). Dysuria: evaluation and differential diagnosis in adults. American Family Physician, 92(9), 778-786 Lorna Durfee Discussion Part One 5/22/2016 3:28:57 PM Subjective: Mrs. Orndorf is a 28-year-old woman married for three years who has just returned from an outdoor camping trip with her husband, with symptoms of dysuria with a burning sensation, the urgency to urinate, and frequent urination. She said, “I have had similar symptoms three times over the last two years. Pubic and low back discomfort awoke me two nights ago, and that is why I am here.” Objective: On physical examination, her temperature was 98.6° F, blood pressure was 114/64 mm Hg, pulse was 68 beats per minute, and the respiratory rate was 12 breaths per minute. Other than a tender abdominal and pelvic area, the examination was unremarkable. Symptoms of dysuria with a burning sensation, the urgency to urinate, and frequent urination. Pubic and low back discomfort two nights ago. Past Medical History: She has had similar symptoms three times over the last two years. What is your list of differential diagnoses in this case and explain how each of these fits with the case patient as described above? Be sure to list at least four (4) pertinent differential diagnoses. Indicate which of these you would select as the most likely diagnosis and explain why. DIFFERENTIALS: Dr. Brown and class: Differential #1 is the most likely diagnosis. # 1: Acute uncomplicated cystitis: Colgan and Williams (2011) explain that urinary tract infections are the most common infections seen in women. Cystitis is an inflammation of the bladder caused by bacterial infection. This patient exhibits some of the symptoms that fit the diagnosis of uncomplicated cystitis. The patient has dysuria with a burning sensation, urgency to urinate, and frequent urination. Also, she has supra-pubic and lower back pain. These symptoms are classic lower urinary tract infection symptoms. Colgan and Williams (2011) state that history, physical examination and as well as urinalysis are important tools for diagnosing uncomplicated cystitis (Colgan & Williams, 2011, p. 771). When there is an acute onset and the patient presents with even one of the symptoms the probability of infection rises 10-fold to approximately 50 percent (Colgan & Williams, 2011, p. 772). This diagnosis fits because this patient has just returned from an outdoor camping trip she may not have had proper bathroom facilities. Also, a woman’s anatomy places her more at risk for infection than men because of the shortness of the urethra as well as the width and the urethra’s proximity to the anus. Improper hygiene after defecation and urination and blood from menstruation increase the risk for infection from bacteria. Sexual activity can also be a path for infection (Gould & Dyer, 2011, pp. 450-451). Bacteria has a very good avenue to travel from the anus to the urethra. Contamination can occur without proper handwashing as well as improper bathing routines. Bacteria can travel from the urethra to the bladder setting the stage for infection. Most infections arise from E. Coli (Gould & Dyer, 2011, p. 450). Most infections are ascending and come from organisms in the perineal area travelling along the continuous mucosa in the urinary tract to the bladder. Next, it moves to the ureters and then the kidney (Gould & Dyer, 2011, p. 450). Colgan and Williams (2011) relate that physical exam in patients with acute uncomplicated cystitis is typically normal except for 10 to 20 percent of women with suprapubic tenderness. If this patient had acute pyelonephritis, she would be much more ill- appearing, with fever, tachycardia and costovertebral angle tenderness (Colgan and Williams, 2011, p. 773). #2: Interstitial Cystitis: Shenot (2014) tells the reader that interstitial cystitis is a bladder inflammation that is noninfectious that causes pain that is suprapubic, pelvic and abdominal. There is chronic inflammation of the bladder. There is also urinary frequency and urgency with incontinence. The cause for this is thought to be the loss of protectiveurothelial mucin and urinary potassium and other substances into the wall of the bladder. Also, other pathophysiology includes activation of sensory nerves and smooth muscle damage. It also appears that mast cells may be a key mediator in the process (Shenot, 2014). Because this patient has a history of having this syndrome three times in the past two years, it raises concern. Because interstitial cystitis worsens over the time, it could mean that her bladder wall has become damaged. The suprapubic and pelvic pressure and pain with urinary frequency and urgency are also very suggestive signs of this disorder (Shenot, 2014). The symptoms can worsen during ovulation, menstruation, allergies, stress and sexual intercourse. Foods with high potassium content seemingly cause exacerbations. Also, the use of tobacco, alcohol, and very spicy foods can worsen symptoms. When the bladder wall becomes scarred, and bladder compliance, as well as capacity, see a decrease, and this causes further symptoms of urgency and frequency (Shenot, 2014). As the history is rather vague and there is no way to know what foods she may have eaten or continues to eat that could exacerbate this condition, or whether any of the other factors mentioned above have a part to play. We do not have enough information at this time. Further assessment and testing should be done due to her repeated episodes over the past two years to rule out interstitial cystitis. An appointment with a urologist is needed. #3: Acute Pyelonephritis: (Colgan, Williams, & Johnson, 2011) relate that acute pyelonephritis is a common bacterial infection of the renal pelvis and kidney seen in young adult women. It is an infection of the upper urinary tract that involves the renal pelvis and kidney resulting from an ascending pathogen that comes up from the ureters and from the bladder to the kidneys (Colgan et al., 2011, p. 519). This infection results in approximately 250,000 office visits each year. The incidence is highest in healthy women 15 to 29. Although this infection can occur in men, children and pregnant women this is only a small percentage (Colgan, et al., 2011, p. 519). In approximately 80 percent of the cases, Escherichia coli is responsible. There are various risk factors and include sexual intercourse three to more times a week during the past 30 days and a history of urinary tract infections in the past 12 months. Stress incontinence can be a risk factor as well as diabetes in the previous 30 days. Also, the addition of a new sexual partner in the previous year and spermicide use can contribute. As this patient has lower tract urinary symptoms of frequency, urgency, dysuria is found with this condition; she is a candidate for this infection. Although she has no fever at present, she still could be harbouring the infection. Because there is no fever, it does not rule out an occult process. If this patient had acute pyelonephritis, she would be much more ill-appearing, with fever, tachycardia, and costovertebral angle tenderness (Colgan and Williams, 2011, p. 773). #4: Nephrolithiasis: Curhan, Aronson & Preminger (2015) relate that renal and ureteral stones are seen most commonly seen in primary care. Patients usually present with renal colic and hematuria. Other patients may present with vague abdominal pain, acute abdominal flank pain, nausea. There is also urinary urgency and frequency and difficulty urinating. Approximately 80 percent of patient with this condition have calcium stones. Other stone types include calcium phosphate, uric acid, struvite, and cystine. The theory is that stone formation happens when the soluble material (calcium oxalate) supersaturates the urine, and this begins the crystal formation process. These crystals are anchored to collection ducts, and their size will increase with time. This process happens at sites of epithelial injury, and the crystals may cause this. Another theory is that stones and their formation begin at the renal medullary interstitium. Calcium phosphate crystals form, in the interstitium and then extruded from the renal papilla. The crystals of calcium oxalate and phosphate deposit on top of this place and then remain attached to the papilla (Curhan et al., 2015). Preminger and Curhan (2015) tell us that approximately 8 percent of women will have at least one stone by the age of 70. These stones will contain calcium oxalate. They also suggest that obesity among women has a part to play in the formation of the stones (Preminger & Curhan, 2015). Gould and Dyer (2011) tell us that stones in the kidney or bladder are asymptomatic frequently. Sometimes flank pain occurs because of distention in the renal capsule. With obstruction of the ureter, there are intense spasms of pain in the flank that radiates into the groin that can last until the stone can be removed. This pain comes from the ureter contractions which is trying to force the stone out. There can be a rapid pulse, nausea, and vomiting (Gould and Dyer, 2011, p. 455). As this patient does not appear to have all the symptoms at this time, it is not the likely diagnosis. According to the first item in your differential, what are the risk factors for this disorder? Also, a woman’s anatomy places her more at risk for infection than men because of the shortness of the urethra as well as the width and the urethra’s proximity to the anus. Improper hygiene after defecation and urination and blood from menstruation increase the risk for infection from bacteria. Sexual activity can also be a path for infection (Gould & Dyer, 2011, pp. 450-451). Bacteria has a very good avenue to travel from the anus to the urethra. Contamination can occur without proper handwashing as well as improper bathing routines. Bacteria can travel from the urethra to the bladder setting the stage for infection, or cystitis. Most infections arise from E. Coli (Gould & Dyer, 2011, p. 450). Most infections are ascending and come from organisms in the perineal area travelling along the continuous mucosa in the urinary tract to the bladder, up to the ureters, and then the kidney (Gould & Dyer, 2011, p. 450). What are some treatments for this disorder? Colgan and Williams (2011) explain that testing for acute uncomplicated cystitis is for nitrites and leukocyte esterase on urine dipstick are most accurate (Colgan and Williams, 2011, p. 773). They relate that treating uncomplicated cystitis would depend the effectiveness of the agent, the side effects, resistance rates and the propensity to cause collateral damage (Colgan and Williams, 2011, p. 773). The cost, availability, patient factors such as allergy should be considered. The guidelines from the Infectious Diseases Society of America (ISDA) recommend the following as first tier antimicrobials: Nitrofurantoin at a dose of 100 mg twice a day for five days, trimethoprim/sulfamethoxazole (Bactrim, Septra) one double-strength tablet twice per day for three days, in regions where resistance does not exceed 20 percent, and fosfomycin at a single dose of 3 g (Colgan and Williams, 2011, p. 774). Beta-lactam antibiotics are not recommended because of the widespread E. coli resistance rates. ReferencesColgan, R., Williams, M., & Johnson, J. R. (2011). Diagnosis and treatment of acute pyelonephritis in women. American Family Physician, 84(5), 519-526. Colgan, R., & Williams, M. (2011). Diagnosis and treatment of acute uncomplicated cystitis. American Family Physician, 84(7), 771, 772. Curhan, G. C., Aronson, M. D., & Preminger, G. M. (2015). Diagnosis and acute management of suspected nephrolithiasis in adults. Retrieved from http://www.uptodate.com/contents/diagnosis-and-acute-management-of- suspected-nephrolithiasis-in-adults Gould, B. E., & Dyer, R. M. (2011). Urinary System Disorders. In Pathophysiology for the health professions (4th ed., p. 450-455). Grover, S., Srivastava, A., Lee, R., Tewari, A. K., & Te, A. E. (2011). Role of inflammation in bladder function and interstitial cystitis. Therapeutic Advances in Urology, 3(1), 19–33. http://doi.org/10.1177/1756287211398255 Preminger, G. M., & Curhan, G. C. (2015). The first kidney stone and asymptomatic nephrolithiasis in adults. Retrieved from http://www.uptodate.com/contents/the-first-kidney-stone-and-asymptomatic-nephrolithiasis-in- adults?source=see_link Shenot, P. J. (2014). Interstitial Cystitis. In Merck Manual online. Retrieved from https://www.merckmanuals.com/professional/genitourinary-disorders/voiding-disorders/interstitial-cystitis Instructor Brown reply to Lorna Durfee RE: Discussion Part One 5/29/2016 3:14:13 PM Interesting that obesity plays a part in women with kidney stones? Could it be from decreased fluid intake, type of food consumed or number of trips to empty bladder? Lorna Durfee reply to Instructor Brown RE: Discussion Part One 5/29/2016 9:22:12 PM Interesting that obesity plays a part in women with kidney stones? Could it be from decreased fluid intake, type of food consumed or number of trips to empty bladder? Dr. Brown: I think that decreased fluid intake, and food consumed as well as number of trips to empty the bladder play are part in the process of stone formation. Lieske (2013) explains that obesity is epidemic in the United States and now affecting > 20 percent of the population. Also, there is a lifetime prevalence of 12 percent in men and 7 percent of women for stone formation, and that stones are responsible for two billion annually in health care costs. The author also tells us that being obese has been associated with stone risk for both men and women. However, the precise pathogenic steps in stone formation remain indefinable. Urinary supersaturation is a prerequisite for stone formation. Stones also develop due to a lower urine volume (less fluid intake) and excretion of calcium, oxalate and uric acid and citrate (Lieske, 2013, p. 1). Also, the development of stones have been associated with dietary factors, and they include the intake of animal protein, low potassium and fluid intake and calcium intake (Lieske, 2013, p. 1). The consumption of fructose and other dietary factors lead to the change of composition of urine which can also play a part. Lieske (2013) also states that the Dietary Approaches to Stop Hypertension (DASH) diet with more intake of fruits and vegetables, low-fat dairy, and low protein decrease the risk of stones (Lieske, 2013, p. 2). He also informs us of the hypothesis that diet is linked to obesity. Stones that contain urine oxalate, uric acid, sodium, and phosphate are documented in men and women with a higher BMI. He also found that urine volume rose in tandem with BMI, such that oxalate supersaturation did not increase. However, urine pH was lower among patients with a greater BMI. These findings coincide with evidence that obesity and insulin resistance is observed with ammoniagenesis, lower pH and increased the risk for stones (Lieske, 2013, p. 2). Lieske (2013) also found that higher caloric intake increased kidney stones. He states that mild to moderate activity may also protect against stone formation. References Lieske, J. C. (2013). New Insights Regarding the Interrelationship of Obesity, Diet, Physical Activity, and KidneyStones. Journal of the American Society of Nephrology, 25(2), 211-212. doi:10.1681/asn.2013111189 Rechel DelAntar Differential Diagnoses 5/22/2016 7:34:52 PM Hello Professor and class, Differential Diagnoses This is a case of 28 year old married female returning with her husband from an outdoor camping trip experiencing symptoms of dysuria, burning upon urination, frequent and urgent urination accompanied by pubic and low back pain, which woke the patient upon several nights before. Expressed she had experienced similar symptoms three times over the past 2 years. Vital signs within limits and patient is afebrile and physical examination is unremarkable except for a tender abdominal pelvic area. Based on this data, patient may be experiencing: 1. Interstitial Cystitis = Cystitis is an inflammation of the bladder. However, not all inflammation is caused by an infection. Interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region. The symptoms vary from case to case and even in the same individual. People may experience mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area. Symptoms may include an urgent need to urinate, a frequent need to urinate, or a combination of these symptoms. Pain may change in intensity as the bladder fills with urine or as it empties. IC is often mistaken for a urinary tract infection (UTI) or bladder infection because of the similarity in symptoms. Medical tests reveal no organisms in the urine of people with IC/PBS. Furthermore, people with IC/PBS do not respond to antibiotic therapy and it occurs more frequently in women and ages 18 and above (National Institute of Diabetes and Digestive and kidney Disease, 2013). In the case of our patient, she is experiencing the same symptoms as Interstitial cystitis such as urinary frequency and urgency with pelvic pain without any signs of infections such as fever or fouls smelling urine. 2. Urinary tract Infection = A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. It occurs mostly among women than men and although some patients have no symptoms, most common signs are a strong, persistent urge to urinate, burning sensation when urinating, passing frequent, small amounts of urine, urine that appears cloudy, urine that appears red, bright pink or cola-colored which is a sign of blood in the urine, strong-smelling urine and pelvic pain, in women especially in the center of the pelvis and around the area of the pubic bone (Mayo Clinic, 2013). Symptoms of the disease match some symptoms experienced by the patient except that the patient is not experiencing having a cloudy or foul smelling urine or any fevers which makes it a plausible diagnosis but not a definitive one unless the patient has a positive urinalysis and cultures. 3. Overactive Bladder = Overactive bladder is an involuntary and sudden contraction of the muscle in the wall of the urinary bladder. OAB affects both men and women and symptoms include frequency and urgency in urination. The most common symptom of OAB is a sudden urge to urinate that you can't control that causes incontinence. In this case, although our patient is experiencing frequent and urgency in urination, she is not experiencing urinary incontinence (US National Library of Medicine, 2016). Also OAB does not explain her pubic and lower back pain. 4. Renal Calculi = is a material which is formed in the kidneys from minerals in urine. Kidney stones typically leave the body in the urine stream, and a small stone may pass without causing symptoms. If stones grow to sufficient size (usually at least 3 millimeters (0.1 in) they can cause blockage of the ureters leading to pain most commonly beginning in the flank or lower back and often radiating to the pubic and groin area. This is called a renal colic and typically comes in waves lasting 20 to 60 minutes. Other symptoms are fever, blood in urine, pus in urine at times and painful urination (Fink, H.A., et. al., 2013). Risk factors associated with Interstitial Cystitis are sex, it occurs mostly in women than in men; age, although it occurs at age 18 most patients are diagnosed in their 30s or older and previous urinary tract infection has been proposed as a possible risk factor for IC. Anecdotal reports suggest that some patients experience the onset of IC/PBS symptoms after an episode of acute bacterial cystitis (National Institute of Diabetes and Digestive and Kidney Disease, 2013). No simple treatment exists to eliminate the signs and symptoms of interstitial cystitis, and no one treatment works for everyone. Medications such as NSAIDs, antihistamines and Pentosan can be used to relieved symptoms of IC. The use of TENS and sacral nerve stimulators in conjunction with medications are also an alternative. People with severe pain or those whose bladders can hold only very small volumes of urine are possible candidates for surgery, but usually only after other treatments have failed. Surgical procedures include fulguration, resection and bladder augmentation (Mayo Clinic, 2014). References: Fink, H.A., Wilt, T.J., Eidman, K.E. and Garimella, P.S. (2013). Medical Management To prevent recurrent nephrolithiasis in adults: A systematic review for An American College of Physicians clinical guidelines. Annals of Internal Medicine. 158(7), 535-543. Mayo Clinic. (2014). Interstitial Cystitis. Retrieved from http://www.mayoclinic.org/diseases-conditions/ interstitial-cystitis/basics/treatment/con-20022439. Mayo Clinic. (2013). Urinary Tract Infection. Retrieved from http://www.mayoclinic.org/diseases-conditions/ urinary-tract-infection/basics/symptoms/con-20037892. National Institute of Diabetes and Digestive and Kidney Disease. (2013). Insterstitial Cystitis/Painful Bladder Syndrome. Retrieved fromhttp://www.niddk.nih.gov/health-information/health-topics/urologic- disease/interstitial-cystitis-painful-bladder-syndrome/Pages/facts.aspx. US National Library of Medicine. (2016). Overactive Bladder. Retrieved from https://www.nlm.nih.gov/medlineplus/overactivebladder.html. Alice Jeffries reply to Rechel DelAntar RE: Differential Diagnoses Rechel, Interstitial cystitis can be hard to diagnose and has similar symptoms to many other disease processes. There are also no specific risk factors for IC, other than possibly genetics (Martin, sheaves, and Childers, 2015). Over one and a half million men and over three million women have IC, which tells us that being a female increases the odds of having IC, as does having a relative with IC, and being over 40 years old (Martin et al., 2016). There are two forms of IC, one being ulcerative with Hunner’s ulcers and more acute and intense pain, and non-ulcerative IC, which is usually more benign (Martin et al. 2016). When diagnosing IC, it is important to also consider and rule out other diagnosis, and also educate patients about possible triggers for flares, and discuss conventional treatments, as well as complementary therapies which can be a very important part of IC treatment (Martin et al., 2015). I find it so exciting that there is so much more information about IC and health care providers have more resources available! Patients can find more resources available and be more educated. Ali Martin, E., Sheaves, C., & Childers, K. (2015). Underlying Mechanisms and Optimal Treatment for Interstitial Cystitis: A Brief Overview. Urologic Nursing, 35(3), 111-116 6p. doi:10.7257/1053-816X.2015.35.3.111 5/29/2016 3:08:38 AM Liberty Neoh Discussion 1 5/23/2016 6:25:40 AM Dr. Brown and Class, What is your list of differential diagnoses in this case and explain how each of these fits with the case patient as described above. Be sure to list at least four (4) pertinent differential diagnoses. Indicate which of these you would select as the most likely diagnosis and explain why. Mrs. Orndorf is experiencing symptoms of urinary tract infection. According to Zak (2015), urinary tract infections are most common reasons women seek medical attention. It is a bacterial infection which involves kidney, ureter, and bladder. Her vital signs are within normal limits. Her complaints are frequent urination, burning sensation, urgency to urinate, and tender abdominal pelvic area. Zak (2015), described in his article similar symptoms but it included hematuria. Possible Differentials: Kidney Stone is caused by stone formation. Our urine is a complex liquid that contains hundreds of chemicals, including many minerals. But if the minerals become supersaturated, they precipitate into crystals that bind with protein and grow into gravel, then stones. Over saturation can occur if excessive amounts of a mineral are excreted into the urine or if the volume of fluid is decreased by dehydration. Pain, is the most common, often severe, and blood in the urine are some of the symptoms associated with kidney stone (Scales et al, 2015). Pelvic Inflammatory Disease is a serious condition which is usually caused by sexually transmitted disease. Patient may have pelvic pain, burning when urinating, and foul smelling vaginal discharge (Birgisson et al, 2015). Extrauterine Pregnancy is the implantation of a fertilized egg outside the uterine cavity. The symptom triad of mild vaginal spotting in the first trimester, aching pelvic pain, and secondary amenorrhea may indicate extrauterine pregnancy but can also arise in an intact intrauterine pregnancy or as a consequence of early miscarriage (Taran et al, 2015). According to the first item in your differential, what are the risk factors for this disorder? Risks factors associated with UTI is related to behavioral practices such as, are incorrect perineal washing technique, use of synthetic or silk innerwear, not sundrying the innerwear, lesser frequency of changing menstrual absorbents (Vyas et al, 2015). What are some treatments for this disorder? According to Zak (2014), “a 3-day treatment is effective for treating uncomplicated acute UTIs. Antibiotic selection includes sulfamethoxazole-trimethoprim, trimethoprim, ciprofl- oxacin, levofloxacin, or a 5-day course of nitrofurantoin when antimicrobial resistance is a concern”. Our patient in this case study seems like she is at an early stage of UTI. In my personal experience, the clinic I went to obtained a urine sample and I was prescribed antibiotic. References Birgisson, N. E., Zhao, Q., Secura, G., Madden, T.,& Peipert, J. F. (2015). Positive testing for neisseria gonorrhoeae and chlamydia trachomatis and the risk of pelvic inflammatory disease in IUD users. Journal of Women’s Health, 24(5). doi: 10.1089/jwh.2015.5190 Scales, C. D., Saigal, C. S., Bennett, C. J., Ponce, N. A., Mangione, C. M., & Litwin, M. S. (2015). Emergency department revisits for patients with kidney stones in California. Academic Emergency Medicine, 22(4). doi: 10.1111/acem.12632Taran, F. A., Kagan, K. O., Hübner, M., Hoopmann, M., Wallwiener, D., & Brucker, S. (2015). The diagnosis and treatment of ectopic pregnancy, 112(41). doi: http://dx.doi.org/10.3238/arztebl.2015.0693 Vyas, S., Sharma, P., Srivastava, K., Nautiya, V.,& Shrotriya, V. P. (2015). Role of behavioural risk factors in symptoms related to UTI among nursing students. Journal of Clinical and Diagnostic Research, 9(9). doi: 10.7860/JCDR/2015/10995.6547 Zak, D. (2015). Managing uncomplicated recurrent urinary tract infections in reproductive aged women: A primary care approach. Journal of the American Association of Nurse Practitioners, 26(12). doi: 10.1002/2327-6924.12110 Anthony Parente Discussion Part One 5/23/2016 2:51:32 PM Dr. Brown and Class, This patient is presenting with symptoms typical of a disturbance within the urinary system. In order to select an appropriate diagnosis, we must first evaluate the presenting problem. Once we have gained an understanding of the patient’s presentation, we can then view symptoms to determine if each differential diagnosis is applicable to the patient. The patient is presenting with recurrent painful urination, increased frequency and urgency to urinate, and back and pelvic discomfort. This is most likely a urinary tract infection (UTI). However, many other diseases can present in a similar nature. In order to determine a definitive diagnosis, the following differential diagnoses have been made: 1. UTI: A UTI is an infection which occurs at any point within the patient’s urinary tract. Bacteria can gather in the urethra, bladder, ureter, kidneys etc. (McCance & Huether, 2014). A UTI is most commonly found within the bladder of women. This is due to the gender’s short urethra. Inflammation occurs within the bladder and results in painful urination, increased frequency and urgency, and pelvic and back pain (Glastonbury, 2012). If untreated the patient can develop urosepsis. Risk factors for a UTI include being a sexually active female, use of barrier contraceptives, menopause, use of catheters, urinary procedures, and immunosuppression. (Glastonbury, 2012) We know that the patient is female, and married, so we can assume she is sexually active. Also, the fact she was recently camping, which may present with inadequate cleanliness, may add to her risks. Treatment would include a urine culture and antibiotics (Glastonbury, 2012). Also treatment must include education and behavior modification to help reduce the risk of reoccurrence. Due to her clinical presentation, paired with her associated risk factors, I would assign this diagnosis. 2. Sexually Transmitted Infection (STI): STIs such as gonorrhea and chlamydia can begin with little to no symptoms. Often times, these STIs present as a frequency and urgency to urinate, and painful urination. Pelvic and back pain can also become evident (McCance & Huether, 2014). However, these STIs differ from UTI’s in discharge, which will likely be seen from the urethra of someone with chlamydia or gonorrhea (McCance & Huether, 2014). With the patient's current presentation, this diagnosis is possible, but unlikely. 3. Urinary Obstruction: Obstruction can occur at any point within the urinary system. Obstruction can occur spontaneously or through physical changes (McCance & Huether, 2014). Stricture of the urinary paths, or calculi can obstruct the flow of urine (McCance & Huether, 2014). Obstructions can result in urgency, painful urination, and back and pelvic pain. Normally the patient does not experience extreme frequency unless the patient has increased fluids to help flush out calculi. This diagnosis is possible but unlikely. 4. Overactive Bladder Syndrome (OAB): OAB is a chronic disease which involves the detrusor muscle. Overactivity of this muscle results in an increase in urinary urgency and frequency (McCance & Huether, 2014). This can present with pelvic pain if the urinary sphincter and bladder become irritated due to frequency, but it is often associated with nocturia. This diagnosis is not likely, since the patient is not complaining of nocturia. Also, this diagnosis is not made without evaluation for acute problems like a UTI. This diagnosis is confirmed through urodynamic study (McCance & Huether, 2014). -Jonathan References: Glastonbury, S. (2012). Evidence based practice review: Cranberry for urinary tract infection prophylaxis in children at risk of recurrent UTI. Australian Journal of Herbal Medicine, 24(2), 56-60. Retrieved from CINAHL Plus with Full Text database. (Accession No. 104429771) McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Elsevier-Mosby. Jonathan Bidey reply to Anthony Parente RE: Discussion Part One Technical Support Case Number: 00130517 ] Dr. Brown, 5/26/2016 6:46:57 PMAs we discussed, there was an administrative mistake made regarding my D#. The above post has been uploaded in the threaded discussion questions under the incorrect name "Anthony Parente." However, as you can see in my signature in the post, my name is not Anthony, it is Jonathan. I appreciate your understanding towards whatever mistake has occurred which caused my D# to generate this error, and I am posting this to help you view which post is actually mine. I have been contacted by Chamberlain that the issue has been resolved for future posts. Thank you again. -Jonathan Bidey Instructor Brown reply to Jonathan Bidey RE: Discussion Part One Jonathan, I think it is fixed. I see your name. Dr. Brown 5/29/2016 3:21:10 PM Alice Jeffries Discussion Part One 5/23/2016 4:13:54 PM Dr. Brown and class, 1. Cystitis, urinary tract infection (UTI): This is my primary differential diagnosis. In the United States, it is estimated that there are more than 10 million office visits a year for patients experiencing UTI symptoms (Flores-Mireles, Walker, Caparon, and Hultgren, 2015). UTIs can occur with people who are otherwise healthy, although there are additional risk factors for individuals who are female, prior UTI, sexually active, experience vaginal infections, diabetic, obese, or are otherwise genetically susceptible (Flores-Mireles, 2015). There are also other reasons for frequent bladder infections with patients who have other comorbidities that were not mentioned in the case study. Patients are usually treated with antibiotics and with recurrent UTI’s a culture should be done to make sure the patient is receiving the correct antibiotic (Flores-Mireles, 2015). Trimethoprim sulfamethoxazole, ciprofloxacin and ampicillin are the most frequently used antibiotics, however because of the frequent use of antibiotics, there has been resistance to common antibiotics (Flores-Mireles, 2015). Additionally teaching regarding fluid intake, not waiting to urinate, and monitoring for worsening signs and symptoms such as flank pain should also be done. 2. Interstitial cystitis/bladder pain syndrome (IC/BPS): This can be hard to diagnose and is often misdiagnosed as a bladder infection. Kahn and Lombardi (2016) stated that this is a common cause of chronic pelvic pain and up to nearly 8 million women may suffer from (IC/BPS). The symptoms of dysuria, urgency, and frequent urination mimic a bladder infection. I want to include this on my differential diagnosis because I was misdiagnosed and treated for many years for recurrent bladder infections. When my daughter went through nursing school (before I was a nurse), she called me and told me about this diagnosis. I found what triggers the episodes and now it is controlled with maybe one or two episodes a year as compared to five to eight episodes. It was extremely painful and often caused bleeding from the bladder. No doctor ever suggested this diagnosis even though there were never bacteria found in the urine samples or cultures. I would like to bring more attention to this diagnosis after I become a NP as I have several women in my family who have had similar experiences as me. Patients who continue to have symptoms of bladder infection, however the cultures are negative, should be tested for IC/BPS (Kahn and Lombardi, 2016). Unfortunately, some of the home remedies such as increasing fluid intake and drinking cranberry juice can make IC/BPS much worse. 3. Diverticulitis: If the diverticulitis is near the bladder nerve, symptoms may be similar to a bladder infection including dysuria, urgency, and frequency (Goroll and Mulley, 2014). This diagnosis is lower on the list because there is no fever associated with the patient’s symptoms. 4. Vaginitis: May mimic cystitis and be mistaken for UTI, however this not usually urgency or frequency with vaginitis (Goroll and Mulley, 2014). There may by dysuria due to localized trauma or irritation (Goroll and Mulley, 2014). Ali Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J. (2015). Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nature Reviews. Microbiology, 13, 269-284. doi:10.1038/nrmicro3432 Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer. Kahn, B. S., & Lombardi, T. (2016). Interstitial cystitis: Simplified diagnosis and treatment. Contemporary OB/GYN, 61, 14-30 6p. Rechel DelAntar reply to Alice Jeffries RE: Discussion Part One 5/24/2016 8:39:14 PMHello Alice and Class, My original diagnosis for this patient was also UTI. Symptomatology of dysuria with a burning sensation, urgency to urinate, and frequent urination is typical of UTI which is A urinary tract infection (UTI) is an infection in any part of your urinary system; your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract, the bladder and the urethra. However, the patient was not experiencing any symptoms of foul smelling or cloudy urine which made me reconsider my diagnosis. However, some UTI patient may not exhibit signs and symptoms of the disease until a urinalysis and culture and sensitivity is done (Mayo Clinic Staff, 2015). The patient may have a UTI but will not be fully proven until testing is done. Reference: Mayo Clinic Staff. (2015). Urinary Tract infection. Retrieved from http://www.mayoclinic.org/ diseases-conditions/urinary-tract-infection/basics/symptoms/con-20037892. Alice Jeffries reply to Rechel DelAntar RE: Discussion Part One Rechel, I was really glad to see that you listed interstitial cystitis as your first differential diagnosis on your post. I went back and forth between UTI and IC. I have seen a lot of UTI's without cloudy or smelling urine, and without a fever, so I did not rule out UTI. Ali Instructor Brown reply to Rechel DelAntar RE: Discussion Part One Your re-thinking is an excellent idea. Testing is always a great way to confirm your diagnosis. Lanre Abawonse reply to Alice Jeffries RE: Discussion Part One 5/27/2016 12:04:57 AM In addition to the treatment you talk about in treating UTI, there are other inexpensive approaches that could easily be used in treating UTI. She should avoid caffeine, alcohol, and spicy foods that can further irritate the bladder. She should take a shower instead of bath, and wear cotton underwear and loose fitting clothes. It’s also important to tell the woman to clean well with soap and water before and after sexual activity and her partner must also do the same. In the case of a simple UTI, drinking 8oz of cranberry juice might be helpful and the use of several capsules of probiotics on a regular basis is an effective way to protect the colon and the vagina. Chisholm (2015) conducted a study on the use of probiotic for recurrent UTI since antibiotic resistance from E. coli to sulfamethoxazole, trimethoprim and amoxicillin increased after one month from 20% to 40% to 80% to 95% in the TMP-SMX group. Chisholm (2015) stated that Lactobacillus probiotics, taken either orally or vaginally, are likely effective in reducing recurrent UTIs in women. Lactobacilli may be especially useful for women with a history of recurrent, complicated UTIs or prolonged antibiotic use. Although Lactobacilli are found slightly less effective than antibiotics in reducing recurrent UTIs (at least in the dose and frequency studied), probiotics do not cause antibiotic resistance and may offer other health benefits due to vaginal re-colonization with Lactobacilli. Reference Chisholm, A. H. (2015). Probiotics in Preventing Recurrent Urinary Tract Infections in Women: A Literature Review. Urologic Nursing, 35(1), 18-29 12p. doi:10. 72 57/10 53-816X.2015.35.1.18 5/29/2016 3:34:36 PM 5/29/2016 2:48:58 AM Alice Jeffries reply to Lanre Abawonse RE: Discussion Part One 5/29/2016 2:39:39 AM Lanre, I appreciate the information about probiotic use. I have been studying it more at work. Also, I have looked at probiotic use for individuals who take antibiotics. I had not heard about probiotic use for people with recurrent UTIs. I appreciate that information and will remember it. I also think the teaching aspect is very important. In the hospital, one nurse wouldn't do the teaching for UTI becauseshe said that everyone should know that information. I reminded her that we all have to hear it for the first time and it was probably a nurse who told us. Even if we patients have heard it before, it will reinforce the education to hear it again, especially if it a recurrent issue. Thank you for your response and information. Ali Lanre Abawonse Discussion Part One 5/23/2016 5:08:46 PM Urinary tract infection (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra. Women are the most affected with about 25% or more affected in their lifetimes. Women are affected more than men due to the anatomical variation of the length of the urethra (1 to 2 inches). Symptoms associated with UTI range from mild to severe are dysuria, frequency, nocturia, suprapubic fullness urgency and burning (Casey, 2014). The patient presents with similar symptom experienced by UTI patients as in dysuria, burning sensation, urgency and frequency, making UTI the likely diagnosis. Pyelonephritis is a type of urinary tract infection of the renal pelvis and renal tissue; it is caused by an invasion of microorganisms. The infection, which primarily affects the renal pelvis, calyces, and medulla, progresses through the urinary tract as organisms ascend the ureters from the bladder because of vesicoureteral reflux or contamination. This can happen to patients with diabetes, hypertension, or chronic cystitis. Escherichia Coli is responsible for 90% of the episodes in a normal anatomic urinary tract system. Proteus Klebsiella, and occasionally gram-positive cocci account for the rest. Assessment should focus on if patient has dysuria, urgency (sign of an irritated urinary tract), frequency and burning sensation before seeking care; we would also need to know if she is experiencing flank pain and if she has a fever (Bethel, 2012). Interstitial cystitis (IC) This is one of many non-specific diagnosis and is known as a pain syndrome characterized by pelvic pain lasting longer than six months, usually perceived from the bladder and accompanied by lower urinary tract symptom (frequency, urgency, dysuria, and dyspareurenia) currently experience by the patient. IC symptoms can become chronic and level out over a year or two (Martin, Sheaves, & Childers, 2015). Pelvic inflammatory disease (PID) is a polymicrobial infectious disease of the pelvic cavity and the reproductive organs. Often it might be localized or widespread involving the whole pelvic region. The infection can be acute or chronic, thus it can be a life threatening and life altering condition. Mycoplasma hominis, Ureaplasma urealyticum and Trichomonas vaginalis are common conditions that can lead to PID. (Abatangelo et al., 2010) symptom include vaginal discharge, dyspareunia, dysuria, frequency, urgency, and burning. According to the first item in your differential, what are the risk factors for this disorder? Predisposing factors include being a woman as UTI affects more women than male. The other risk factors are urethra damage from childbirth, catheterization, or surgery; decreased frequency of urination; other medical condition such as diabetes mellitus; frequency of intercourse, spermicide use, new sexual partner within the previous year, prior history of UTIs, and institutionalization (Shah, Goundrey-Smith, 2013). What are some treatments for this disorder? There are non-pharmacological and pharmacological processes of treating UTIs. The patient should be encourage to eat foods from the acid-ash diet (prunes, eggs, cheese, cranberries, plums and meat) and whole grains; these components increase urine acidity. Nitrofurantoin maybe used since UTI medication is diminished by acidic urine; others are cephalosporins, ciprofloxacin, sulfisoxazole, and co-trimoxazole. Nitrofurantoin will cause bacteriocidal concentration in the urine and kidneys to kill bacteria. Prescribe a minimum of 2 weeks antibiotics based on antimicrobial sensitivities with repeat urine check after the treatment (Hofkamp, & Fields, 2015). Reference Bethel, J. (2012). Acute pyelonephritis: Risk factors, diagnosis and treatment. Nursing Standard, 27(5), 51-56 6p. Black, A. (2014). Management of pelvic inflammatory disease. Nurse Prescribing, 12(9), 443-450 8p.Casey, G. (2014). Understanding urinary tract infections. Kai Tiaki Nursing New Zealand, 20(5), 20-23 4p. Hofkamp, H., M., & Fields, S., A. (2015) Urinary Tract Infection. In F. J. Domino (Ed.), The 5-minute clinical consult (Electronic). Philadelphia, PA: Wolters Kluwer Health. Martin, E., Sheaves, C., & Childers, K. (2015). Underlying mechanisms and optimal treatment for interstitial cystitis: A brief overview. Urologic Nursing, 35(3), 111-116 6p. doi:10.7257/1053-816X.2015.35.3.111 Shah, C., & Goundrey-Smith, S. (2013). Managing the symptoms of urinary tract infection in women. Journal of Community Nursing, 27(4), 88-92 5p. Brittany Heller UTI 5/24/2016 12:56:06 PM Due to the patient’s symptoms, I believe she has an UTI. The most common site of a UTI is acute cystitis which would be my first diagnosis. There are two factors that contribute to the presence of an UTI. The first being the efficiency the host has with defensive mechanisms against bacteria. The second being the virulence of the pathogens (McCance & Huether, 2014, p. 1350). Acute cystitis: is an inflammation of the bladder (McCance & Huether, 2014, p. 1350). This type of UTI is more common in women due to the anatomy of the female urinary tract and having a smaller urethra and also due to the proximity of the vagina and anus (McCance & Huether, 2014, p. 1350). The two types of bacteria that cause the most E.Coli and Staphylococcus saprophyticus . The bacteria infects the bladder by by retrograde movement of the sterile urine back to the bladder (McCance & Huether, 2014, p. 1350). Signs and symptoms include frequency, urgency, dysuria, and suprapubic and low back pain. The patient presents with all these symptoms so this would make this the most likely diagnosis. Painful Bladder Syndrome: is a condition associated with either nonbacterial infectious cystitis and noninfectious cystitis (McCance & Huether, 2014, p. 1351). This syndrome typically occurs in women between the age range of 20-40 years old and who have symptoms of cystitis for more than 6 weeks but have negative urine cultures (McCance & Huether, 2014, p. 1351). “The cause of PBS/IC is unknown, but an autoimmune reaction may be responsible for the inflammatory response, which includes mast cell activation, altered epithelial permability, neuroinflammation, and increased sensory nerve sensitivity” (McCance & Huether, 2014, p. 1351). This would be my second likely diagnosis once everything else was ruled out. The patient has all the symptoms of an UTI and has had similar symptoms over the past 2 years. She also meets the age range this syndrome typically occurs. Acute Urethral Syndrome: is often described as frequent urination and dysuria without signs of an infection (Terris, 2015, p. 1). Urethral Syndrome was thought to be caused by urethral stenosis. There are other causes that are being theorized which include hormonal imbalances, UTI, traumatic sexual intercourse, and environmental chemicals (Terris, 2015, p. 2). C.trachomatis is also that to be the cause of painful urination and frequency (McCance & Huether, 2014, p. 931). Women are more likely to have this syndrome and are more common in white women (Terris, 2015, p. 3). Gonorrhea: is a STD caused by the bacteria gonococci that have perpetrated the genitals and the urinary tract. In women gonorrhea can also affect the cervix, fallopian tubes, and ovaries, which would cause chronic pelvic pain (McCance & Huether, 2014, p. 1735). Women are have a risk of contracting gonorrhea if they have intercourse with an infected male partner up to 80% (McCance & Huether, 2014, p. 919). The microograngisms become attached to the plasma membranes of these epithelial cells of the mucous membranes and then they invade the cells and begin damaging the host cells (McCance & Huether, 2014, p. 921). Signs and symptoms for women include: dysuria, increased vaginal discharge, abnormal menses, lower abdominal/back pain, and dyspareunia (McCance & Huether, 2014, p. 921). The patient does present with some of these symptoms but since she is married this does push this diagnosis at the lower part of my list. The risk factors associated with UTIs and acute cystitis is associated with age, sex, and anatomy of the individual. A urine analysis and urine culture is the first test that would be ordered. If the UTI is uncomplicated then a multi day antibiotic treatment may be appropriate for this patient. The most common course of treatment is a selected antimicrobial that would take approximately 3 to 7 days (McCance & Huether, 2014, p. 1351). McCance, K. & Huether, S. (2014) Pathophysiology: The Biologic Basis for Disease in Adults and Children (7 ed). St. Lois: Elsevier. th Terris, M. (2105) Urethral Syndrome. MedScape.com Retrived at: http://emedicine.medscape.com/article/451683-overview#a7 Instructor Brown reply to Brittany Heller RE: UTI Explain the patho process causing the increased vaginal discharge. Heather Orr Mrs. Orndorf 5/24/2016 2:34:54 PM 5/26/2016 6:58:45 AM [Show More]

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