• Gynecologic complaint
  • – DDx. Given nature of presenting complaint (CC), pt was evaluated emergently for the following to determine if need for emergent diagnostics/interventions. When upon my eval, the hx/exam was exceeding clear that more emergent morbid/mortal pathologies were not in any reasonable refined ddx to this pt's presentation, further work up was not unnecessarily pursued to prevent putting pt at – in my professional opinion – were not indicated risks and outweighed benefit.  Guidance was by consideration and appreciation for pt's best interest. 
  •     Initially considered pregnancy related pathologies including ectopic, abortion, however subsequent to negative pregnancy test appreciated that is exceedingly unlikely that pregnancy related pathology was causing patient symptoms
  •     Considered gynecologic causes, gastroenterological causes,
  • – A/P:
  • – ED Course:
  •      Placed on monitor, laboratory analysis performed, urine studies performed
  • – Diagnostically: (aspects of evaluation emphasized given significant contribution to MDM):
  •       Pregnancy test negative
  •     CBC notable for mild leukocytosis
  •     BMP notable for elevated glucose without
  •     Urinalysis consistent with urinary tract infection, given blood on UA suspect hemorrhagic cystitis
  • – Therapeutically: 
  •      Antibiotics.    
  • Considered need for IV antibiotics however given patient is systemically well, tolerating p.o.'s without difficulty, does not appear systemically unwell, I suspect that a trial of p.o. antibiotics as appropriate and discussed with patient importance of return precautions should she develop nausea vomiting that precludes her from taking her antibiotics or if she has any continued or worsening symptomatology.
  • Administered first dose of IV ceftriaxone here in emergency department to assist patient's initiation of antibiotics until patient has steady state of antibiosis and broad and therapeutic levels via p.o. antibiotics 
  • – MDM: 
  •     Suspect hemorrhagic cystitis given urine analysis consistent with infection, urine pregnancy negative, patient has symptomatology of dysuria and hematuria.
  • – Diagnosis:
  • –     (most consistent with dx above wth understanding for diagnostic limitations due to emergent setting of encounter)
  • –     Doubt: (evaluation was not sufficiently consistent the following entities to meet threshold for ED further diagnostics/interventions making risks outweigh benefit of further diagnostics/interventions for the patient i.e. not consistent with these etiologies. consideration included but limited to these conditions): 
  • Not consistent with nephrolithiasis given no flank pain and patient states no pain at all except when she is urinating.  Therefore while I considered that patient could get CT, the diagnostic utility is exceedingly well and the risks with radiation exceed benefits.
  • Not consistent with pyelonephritis given no flank pain, patient is nontoxic, and given constellation of all findings, does not appear to be systemically unwell and has normal vital signs, tolerating p.o.'s.
  • Given systemically well, and no significant flank pain, risk of emphysematous pyelonephritis is less likely.
  • Considered gynecologic pathology including TOA, torsion howeve patient states pain is coming from urine and not from her vaginal vault.  Additionally patient does not have pain on palpation nor on history.
  • Consider sexual transmitted infection however patient denies any risk factors and discussed and offered pelvic exam to patient however patient shared decision-making declined stating that she did not have symptoms that made her concern for sexually transmitted infection nor was amenable to pelvic exam at this time.  I will oblige patient's wishes.  This is reasonable given patient has no significant risk factors. 

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