Pelvic Discomfort in an Elderly Female Patient

Subjective

Chief Complaint

“I feel weak, and a pressure in my pelvis.”

HPICC

The case of a 72-year-old female with a past medical history of osteoporosis, osteoarthritis comes to visit for pelvic discomfort and weakness starting one week ago.

She was feeling well and active, but this time she just does not feel well. She had mild bilateral knee pain due to arthrosis for years, controlled with Acetaminophen when needed. She denies fever, burning urination, lower back pain, leg pains, constipation, diarrhea, or vaginal discharge.

Medications

Acetaminophen 500 mg PRN.

Alendronate 70 mg PO weekly Calcium and Vitamin D 1200 and 5000 U.

PMH

Allergies: The patient does not suffer from any environmental, food, or drugs allergies

Medication Intolerances: KDA

Chronic Illnesses/ Major trauma

Osteoporosis two years ago on Alendronate 70 mg PO weekly Calcium and Vitamin D 1200 and 5000 U

Osteoarthritis on Acetaminophen 500 mg

LMP three weeks ago 42 years ago G3 P3. The patient denies having major traumas.

COLONOSCOPY 2016 Normal

MAMMOGRAM 2016 Bi Rads 2

PAP SMEAR 2014 Normal

Family History

Father died in an accident at 51. Negative for hypertension, cancer, heart disease, diabetes, tuberculosis, and other medical illnesses.

Mother died in a car accident at 46 Negative for diabetes, cancer, hypertension, heart disease, tuberculosis, other medical illnesses.

Social History

The patient is socially active and retired. She spends her daytime attending meetings, conferences and visiting underserved areas for social help with her husband. She never used tobacco or drugs. She drinks one glass of wine a day or two glasses a week. She is sexually active.

ROS

General

The patient is feeling abnormally with poor energy without strength. She denies weight loss/gain, fever, and night sweats.

Skin

No rash, lesions, bruising, bleeding, senile spots over arms and legs.

Eyes

She uses glasses to improve her vision. The patient denies blurring, visual changes.

Ears

The patient had no ear pain, ringing in the ears, etc. There are no reports of ear traumas or hearing loss.

Nose/Mouth/Throat

The patient does not have a sore throat or any oral cavity complaints.

Breast

The patient denies feeling lumps, bumps, or changes.

Heme/Lymph/Endo

She denies having a blood transfusion, extreme sweating, changes in her appetite, lumps, bleeding, or equimosis.

Cardiovascular

She denies chest pain, edema, orthopnea, palpitations.

Respiratory

The patient denies shortness of breath, cough, congestion, wheezing, hemoptysis, and dyspnea.

Gastrointestinal

Abdominal bloating when eating fatty food or too much. No abdominal pain, diarrhea reflux.

Genitourinary / Gynecological

The patient feels mild discomfort in her pelvic area. She found this one week ago a mild pressure above the pubis.

No history of STDs or vaginal infections.

Musculoskeletal

Bilateral knee pain when walking more than 30 minutes or climbing stairs. She takes Acetaminophen when needed.

Neurological

She does not experience spontaneous episodes of weakness, memory loss.

Psychiatric

Denies depression, sleeping disorder, or suicidal attempts.

Objective

Weight: 176lbs.

BMI: 29.3

Temp: 98.2 F tympanic

BP:130/86 right arm, sitting

Height: 5’5”

Pulse: 68 x min

Resp: 14 x min. Oxy Sat 98%

General Appearance

Female. Not in distress cooperative, answers questions willingly and appropriately.

Skin

The patient’s skin is warm, clean, with age spots in the arms and legs area. No petechiae ecchymosis or moles were found.

HEENT

The patient’s head is norm-cephalic, is symmetric, no lesions found. Her hair is distributed in accordance with her sex and age. No tenderness.

The patient’s eyes demonstrate no abnormal signs. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear.

Ears: Symmetric, normal hearing tympanic positive light reflex.

Nose: No visible septum deviation, fine and pink mucosa, no polyps.

Neck: Symmetric, no nodes, no thyromegaly. No gingival edema.

Cardiovascular

No extra sounds are discovered during the patient’s investigation. The rate and rhythm are regular. Capillary refill – 1.6 seconds. There is no edema.

Respiratory

The patient’s chest wall is symmetric expansion. She demonstrates regular respirations. There are no problems with breathing.

Gastrointestinal

The patient’s abdomen is obese. Soft bowel sound present. No epigastric tenderness to deep palpation No masses. Active in all quadrants.

Breast

Symmetric breast no masses no edema or erythema.

Genitourinary

External exam: Vulva inspection with no edema, pubic hair scarce, atrophic changes found. Urethral edema and erythema. Speculum found vaginal walls thin and dry, os closed, no masses, no discharge, mild cystocele, and rectocele. Suprapubic tenderness when performing bimanual palpation. A rectal exam demonstrates the absence of pain, masses, or signs of trauma. No bleeding signs were found. The urine sample was taken for an site exam.

Musculoskeletal

Bilateral knee pain to palpation, full range of motion, locomotor apparatus is fine. Muscular strength 5/5 four limbs.

Neurological

The patient’s speech is clear. She responds to all answers appropriately. Demonstrates an appropriate level of cognitive activity. DTR patellar reflexes are intact 2/2 patellar. Balance is stable.

Psychiatric

The patient maintains eye contact. Speech is clear. Understands all questions. No visible signs of mental disorders. The family history also does not contain any records of this sort.

Lab Tests

Dipstick UA: Bacteria ++ Blood ++ WBC ++ Nitrites+ Glucose Neg, Protein +

Urinalysis diagnoses urinal tract infections by looking for evidence of infection. Some of the indicators of infection include the presence of bacteria or white blood cells in urine. Dipstick urinalysis is a simple, fast, and convenient test that can be performed in an office setting in cases of suspected urinary tract infection (UTI) (Simati, Kriegsman, & Safranek, 2013). Dipstick urinalysis is reported to have a sensitivity of between 80% and 90%, as well as a specificity of 50% (Mambatta, Jayalakshmi Jayarajan, Harini, S., Menon, & Kuppusamy, 2015). Components such as nitrates, the enzyme leukocyte esterase, protein, and blood are valuable in diagnosing UTIs. Certain infectious pathogens can reduce dietary nitrates found in urine to nitrite, which is an indication of bacteriuria. However, this test can also be used to narrow down to specific groups of infecting bacteria. Gram-negative bacteria such as Escherichia coli, Proteus spp., and Klebsiella pneumonia are capable of this reaction in addition to the leukocyte esterase reaction (Mambatta et al., 2015). UTI cases are also characterized by small quantities of protein and red blood cells. The presence of proteins is attributed to protein-containing substances, for example, leukocytes, bacteria, and mucus. The patient’s urinalysis results indicate the presence of bacteria and white blood cells, which point towards infection in the urinary tract.

Special Tests

Calcium test: The purpose of this test is to quantify the concentrations of calcium in the blood. Consequently, this test is useful in screening patients for kidney disease. Normal blood calcium concentrations should range from 8.5 to 10.2 mg/dL. Any values that fall below the normal range are indications of kidney failure (Bodro et al., 2015). The patient has a history of osteoporosis, which is associated with low calcium levels. Therefore, a calcium test is necessary to rule out the possibility of kidney failure.

Assessment Findings and Plan

Differential Diagnoses

UTI

UTI is an infection of the urinary tract caused by the entry of bacteria into this area. The signs of UTIs include lower abdominal pain, burning sensation when passing urine, and an increased frequency of urination. The patient does not complain of frequent urination, itching, and discomfort when urinating. However, she explains that she experiences an uncomfortable feeling and pressure on her lower abdomen. Additionally, the dipstick urinalysis findings show white blood cells, nitrates, blood, and proteins, which indicate the likelihood of UTI (Strasinger & Di Lorenzo, 2014).

Vulvovaginal Candidiasis

Candidiasis is a fungal ailment brought about by excessive growth of Candida species, particularly Candida albicans, which is a normal flora of the vagina. Excessive growth is often caused by hormonal alterations, ailments such as diabetes and HIV, practices such as douching and taking prescriptions of broad-spectrum antibiotics that can promote the propagation of Candida species (Gandhi, Patel, & Jain, 2015). The common symptoms of Candidiasis include a burning sensation, itching as well as the secretion of a profuse, white curd-like vaginal discharge (Clancy & Ngunyen, 2013). The vaginal area may also have a reddish rash. The patient does not exhibit these symptoms, which rules out the possibility of this diagnosis.

Kidney Infection

Kidney infections may manifest with symptoms of UTIs such as inflammation of the urethra, itching, and lower abdominal pain. However, additional symptoms include fever (with body temperatures higher than 37.7◦C), pain in the flank, queasiness, and vomiting (Kauffman, 2014). The patient reports the symptoms of UTIs but does not complain of any nausea, vomiting, or flank pain, which eliminates the possibility of this diagnosis.

Treatment

The patient should receive oral sulfamethoxazole-trimethoprim 800 mg-160 mg every 12 hours for 10 to 14 days (Al-Badr & Al-Shaikh, 2013). Ibuprofen 400 mg every 8 hours should be administered to manage the abdominal discomfort.

Follow-up

Follow-up testing may not be necessary if the symptoms resolve the following treatment. However, if symptoms persist, the patient may be asked to provide urine samples for urine culture and sensitivity testing. The purpose of these tests is to identify the causative organism for specific antimicrobial therapy.

Self-Assessment

The patient was informed that her symptoms should resolve at least 24 hours following the commencement of treatment. She was advised to return to the clinic if her symptoms persisted for more than two or three days afterward. Additional advice included practicing post-coital voiding of the bladder because she admitted to being sexually active. She was encouraged to clean the genital areas before and after intercourse and wipe from front to back to prevent the introduction of bacteria such as E. coli from the perigenital area to the urethra (Al-Badr & Al-Shaikh, 2013). She was asked to stay away from tight undergarments and avoid potential allergens from bubble baths, vaginal creams, deodorant sprays, soaps, and lotions. She was advised to take plenty of fluids and pass urine more often to assist in flushing bacteria from the bladder. Keeping urine for protracted periods facilitates the multiplication of bacteria within the urinary tract, which may lead to cystitis. The patient was asked to avoid vaginal douching because it may inflame the vagina and urethra and promote the entry and establishment of pathogenic bacteria within the urinary tract.

References

Al-Badr, A., & Al-Shaikh, G. (2013). Recurrent urinary tract infections management in women: A review. Sultan Qaboos University Medical Journal, 13(3), 359-367.

Bodro, M., Sanclemente, G., Lipperheide, I., Allali, M., Marco, F., Bosch, J.,… Moreno, A. (2015). Impact of antibiotic resistance on the development of recurrent and relapsing symptomatic urinary tract infection in kidney recipients. American Journal of Transplantation, 15(4), 1021-1027.

Clancy, C. J. & Ngunyen, M. H. (2013). Finding the “missing 50%” of invasive candidiasis: How nonculture diagnostics will improve understanding of disease spectrum and transform patient care. Clinical Infectious Disease, 56(9), 1284-1292. doi: 10.1093/cid/cit006

Gandhi, T. N., Patel, M. G., & Jain, M. R. (2015). Prospective study of vaginal discharge and prevalence of vulvovaginal candidiasis in a tertiary care hospital. International Journal of Current Research and Review, 7(1), 34-38.

Kauffman, C. A. (2014). Diagnosis and management of fungal urinary tract infection. Infectious Disease Clinics, 28(1), 61-74.

Mambatta, A. K., Jayalakshmi Jayarajan, V. L. R., Harini, S., Menon, S., & Kuppusamy, J. (2015). Reliability of dipstick assay in predicting urinary tract infection. Journal of Family Medicine and Primary Care, 4(2), 265-268.

Simati, B., Kriegsman, W., & Safranek, S. (2013). American Family Physician, 87(10): online. Web.

Strasinger, S. K., & Di Lorenzo, M. S. (2014). Urinalysis and body fluids. Philadelphia, PA: F. A. Davis.

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