Case Introduction

Day
1
Office

11 : 00

A 25- year old fema l e presents to t he office with urinary freque ncy a nd burni ng. She i s well- developed,
well- nourished, a nd i n no apparent distress.

Initial vital signs

Da y 1
Initial vital s igns
Tempe r ature:
Pulse:
Respiratory r ate:
Blood pressure , s y stolic :
Blood pressure , diastolic :

He ight:
We ight:
Body Mass I ndex:

11 : 00

37 . 2 de grees C (99 de grees F)

80 beats/min
Re gula r rhyt hm
14 /minute
130 mm Hg
80 mm Hg
167 em (65 . 7 i n )
60 kg (132 . 2 lb)
20 . 7 kg/m2

Initial History

Initial history
Reaso n (s ) for vis i t:

Frequent, pain f ul urination

History of Present Illness:
A 25- year old fema l e presents to t he office because of a t hree day history of burn i ng urination ,
urge ncy, a nd freque ncy. She a l so complain s of s uprapubic discomfort. There has been no vagi na l
discharge, fe ver, chills, hematuria, or f l a n k pain . She has no previous history of sexua lly
tran smitted disease or urin ary tract i n fect ion s. She i s sexua lly active i n a mon ogamous relation s hip

wit h her husband. The y do not u se contraception . Her l ast me n strua l period was 24 days ago.
Past Medical History :
Hospi ta li zation s / Procedure: Non e

Ot her medica l problems: None

CUrre n t medication s: Non e

Allergi es: None

Vacci n ation s: Up to date

..,

Initial History
CUrrent medication s: None
Allergies: None

Vacci nation s: Up to date

Family History:

Father, age 50, a nd mot her, age 47, are both hea l t hy . No family history of diabetes, hyperten s ion , or
cancer.
Social History:
Marital/Family: Married for 3 years a nd has no children

Persona l Habi ts: Has been s moking 10 cigarettes per day for t he l ast seve n years a nd
drin ks a lcohol on weekends
Occupationa l/Educationa l : I s a persona l secretary at a loca l office

Recreationa l : Softball; reading

Re view of Systems:

..,

Initial History

Persona l Habi ts: Has been s moking 10 cigarettes per day f or t he l ast seve n years a nd
drin ks a lcohol on weekend s
Occupationa l/Educationa l : I s a persona l secretary at a loca l o ff ice
Recreationa l : Softball; reading
Re vie w o f Systems:
Ge nera l : See HPI
Skin : Negative
HEENT : Negative
Musculoskel eta l : Negative
Cardiorespiratory : Negative
Gastrointesti na l : See HPI
Ge n i t ourinary : See HPI
Neuropsychiatric: Negative

History and Physical

Day 1 @ 11 : 17

Interval/follow up history
There has been no s igni f ica nt change i n patient's condition
General appearance
Well-developed, well-nouris hed, i n no apparent distress.

Skin examination
Normal t urgor . No nodules or other l esion s, ha ir a nd na ils normal.
Breast examination
Nipples normal; no masses.

Lymph node examination

No abnormal lymph nodes.
HEENT/Neck examination
Normocephalic a nd atraumatic . Pupils are equa l, round a nd reactive to light a nd accomodation .
Vis ion normal. Eyes, i ncluding f unduscopic examination , normal. Heari ng normal. Ears, i ncluding

..,

History and Physical

HEENT/Neck examination
Normocephalic a n d atraumatic . Pupils are equa l, roun d a n d reactive to light a n d accomodation .

Vis ion normal. Eyes, i ncluding f unduscopic exami nation , normal. Heari ng normal. Ears, i ncluding
pinae, externa l a uditory cana l s, a nd t ympa n ic membra nes, normal. Nose a nd mout h normal. Pharynx
normal. Neck i s s upple; no masses or bruits. Throid i s normal.
Chest/Lung examination
Chest wall normal. Di aphra gm a nd chest move equa lly a nd s ymmetrica lly with respiration . No
abn ormality o n percussion or a u scultation .

Cardiovascular examination
5 1 a nd 52 normal. No murmurs, rubs, gallops, or extra s ounds. Centra l a nd peripheral pulses
normal. No j ugul ar ve nous distent ion . Blood pressure equa l i n both ha nds.
Abdominal examination
Abdomen i s soft a nd non- distended. Mild s uprapubic tenderness i s present. Bowel s ounds normal; no
bruits. There are no palpable masses; t here i s no hepatospl e nomegaly.

..,

History and Physical

normal. No j ugular ve nous distent ion . Blood pressure e qua l i n both ha nds.
Abdominal examination
Abdome n i s soft a nd non- distended. Mild s uprapubic tenderness i s present. Bowel s ounds normal; no
bruits. There are no palpable masses; t here i s no hepatospl e nomegaly.
Genital examination
Normal l abi a, n o v agi n a l or cervical discharge, n o v agi n a l or cervical l esion s, u terus n ot

e n l arged. No adnexa l masses or tenderness.

Rectal examination

Sphincter t one normal. No masses or abnormality. Stool brown ; no occult blood.

Extremities/ Spine examination
Extremit i es s ymmetric wit hout deformity or clubbing; no edema. Bilateral peripheral pulses normal.
No j oint deformity or wa rmt h ; f ull range of mot ion . Spine exami nation normal.
Neurologic/ Psychologic examination
Menta l statu s normal. Muscle power i s 5/5 i n a ll f our extremit i es; deep tendon reflexes are wit hin

History and Physical

bruits. There are no palpable masses; t here i s no hepatospl e nomegaly.

Genital examination
Normal l abi a, n o v agi n a l or cervical discharge, n o v agi n a l or cervical l esion s, u terus n o t

e nl arged. No adnexa l masses or tenderness.

Rectal examination

Sphincter t one normal. No masses or abnormality. Stool brown ; no occult blood.

Extremities/ Spine examination
Extremities s ymmetric wit hout deformity or clubbing; no edema. Bilatera l peripheral pulses normal.
No j oint deformity or wa rmt h ; f ull range of mot ion . Spine examination normal.
Neurologic/ Psychologic examination
Menta l statu s normal. Muscle power i s 5/5 i n a ll f our extremit i es; deep tendon reflexes are wit hin
normal limit; t here i s no Babi n ski reflex. Muscle t one a nd bulk are wit hin normal limits. Sen sory
examination i s wit hin normal limits. All crani a l ne rve f unction s are i ntact. Cerebellar f unction
testi ng i s wit hin normal limits. Gait i s normal.

'I"P"tii.D-
iA.P.P.'.O:".Cii]LScoring I Clock ManagementI

APPROACH TO THE CASE

This 25-year-old woman presents t o t he office with urinary frequency, urgency and burning as well as suprapubic
t enderness. She is afebrile and hemodynamically stable. She denies vaginal discharge or f lank pain, and is sexually
acti ve with her husband . She does not practi ce cont raception, and her last menstrua l period was 24 days ago. She is
also a smoker.
These are t he most import ant det ails t o not e from t he pati ent 's initial present ati on, which should ra ise suspicion for
acut e cystitis . The differenti al diagnosis for dysuria in a young woman also incl udes pyelonephritis, pelvic
inflammat ory disease (PID), uret hritis, cerv icitis, and vaginitis . Furt hermore, t his woman is of reproductive age and is
sexually acti ve, and must receive a pregnancy test.
A focused physical examinati on t hat incl udes abdominal and genital exams should be performed on t his pati ent .
However, a complet e physical examinati on is also acceptable. The physical exam revea ls suprapubic t enderness, but is
ot herwise normal. There are no abnormalities on pelvic exam, which makes PID, uret hritis, cerv icitis, and vaginitis all
less li kely. The absence of fever and f lank pain makes pyelonephritis less li kely.
The results of UA (positive nitrite and leukocyt e est erase) confirm t he presence of acut e cystitis . The pregnancy t est is
positive, which must be t aken int o considerati on when selecti ng an anti biotic reg imen . This pati ent also requ ires
pregnancy counseli ng, prenat al vitamins, and prenat al fo llow-up . In pregnant pati ents, urine culture should be ordered
and re peat ed one t o t wo weeks aft er t reat ment t o ensure eradicati on of bact eriuria.
Treatment of cystitis:
Uncomplicat ed cystitis (Normal healthy nonpregnant women) :
3-day course of TMP-SMZ
If allergic t o TMP-SMZ t hen a 3-day course of f luoroquinolone (i.e. ciprofloxacin)
Complicated cystitis (male, diabet es, anat omic abnormality, indwelli ng cat het er, sympt oms > 7 days, recurrent UTI,
>65 yrs age group) :
7-day TMP-SMZ
Cystitis in Pregnancy :

USMLEWORLD CCS - Explanation

[A.i)i)'.()".(ii]LScoring I Clock Management!

"1

'1

.,. .

. ,. .

"

'

'1

acti ve with her husband. She does not practi ce cont racepti on, and her last menst rua l period was 24 days ago. She is
also a smoker.
These are t he most import ant det ails t o not e from t he pati ent 's initial present ati on, which should ra ise suspicion for
acut e cystiti s . The differenti al diagnosis for dysuria in a young woman also incl udes pyelonephritis, pelvic
inflammat ory disease (PID), uret hritis, cerv icitis, and vaginitis . Furt hermore, t his woman is of re producti ve age and is
sexually acti ve, and must receive a pregnancy test.
A focused physical examinati on t hat incl udes abdominal and genital exams should be performed on t his pati ent .
However, a complet e physical examinati on is also accept able. The physical exam revea ls suprapubic t enderness, but is
ot herwise normal. There are no abnormalities on pelvic exam, which makes PID, uret hritis, cerv icitis, and vaginitis all
less li kely. The absence of fever and f lank pain makes pyelonephritis less li kely.
The results of UA (positive nitrite and leukocyt e est erase) confirm t he presence of acut e cystiti s . The pregnancy t est is
positive, which must be t aken int o considerati on when selecti ng an anti bioti c reg imen . This pati ent also requ ires
pregnancy counseli ng, prenat al vitamins, and prenat al fo llow-up. I n pregnant pati ent s, urine culture should be ordered
and repeat ed one t o t wo weeks after t reat ment t o ensure eradicati on of bact eriuria.
Treatment of cystitis:
Uncomplicat ed cystiti s (Normal healthy nonpregnant women) :
3-day course of TMP-SMZ
If allergic t o TMP-SMZ t hen a 3-day course of f luoroquinolone (i.e. ciprofloxacin)
Complicat ed cystiti s (male, diabet es, anat omic abnormality, indwelli ng cat het er, symptoms > 7 days, recurrent UTI,
>65 yrs age group) :
7-day TMP-SMZ
Cystiti s in Pregnancy :

7-day course of nitrofurant oin

If allergic, t hen a 7-day course of amoxicilli n-cl avulanat e
Avoid t rimet hoprim (TMP) as it is a fo lic acid ant agonist
Avoid FQ (ciprofloxacin) due t o risk of cartil age damage

Hence, in t his pregnant fema le, a 7-day course of nitrofurant oin should be ordered.

USMLEWORLD CCS - Explanation

Approach I[S.c0.ri".9.:if Clock Managemenil

"'

SCORING
Examples of actions that will add points to, have no effect on, or subtract points from the score

Optimal
( Most e ffectiv e
managem ent)

Neutral
{Neither harmful nor helpful in
this case)

Suboptim al
(Pot entially har mful or not cost
e ffective )

Physical
Genera l
exam ination Chest/lung
Cardiovascular
Abdominal
Genital

Skin
Breast
Lymph node
HEENT/Neck
Rect al
Ext rem ities/ spi ne
Neurologic/psychologic

!)Fa ilure to order a physica l

examination
2)Delayed abdominal/genital
examination

Diagnostic
tests

B-HCG ,quantitati ve
Gonococcal culture
Chlamydia! cul t ure
Pap smear
Lipid profile

Emer gency None

or ders
(before
physical
examination)

l)B-HCG (qualitative)
2)U/A
3)Urine culture

!)Delay in diagnosis from failing

to order U/A and/or B-HCG
2)0rdering invasive tests t hat
will subject the patient to
discomfort or risk and add no
benefit to the patient care such
as cystoscopy
3)Pursuing alternative diagnoses
lwith..tJ'!SL'-S"'"h ''"'
fnr

...

USMLWORLD CCS- -

1H

[ Clock

'"'"

,.,
B-HCG ,quantitative
Gonococcal culture
Chlamydia! culture
Pap smear
Lipid prof ile

Diagnostic
t ests

l )B-HCG (quali tative)

2)U/A
3)Urine culture

Ther apy

Nitrofurantoin
Prenatal Vitamins
Counseling

l)Delay in treatment with

antibiotics
2)0rdering medications that are
teratogenic or contra indicat ed
during pregnancy:
Quinolones
Tetracyclines
TMP (avoided during t he 1st TM)

Monitoring

Follow-up urine culture one

t o two weeks after therapy

Fail ure to ensure eradicat ion of

bacteriuria

Location

Office, then
Home

Ward (inpatient unit)

ICU
ED

Timing

Confirm pregnancy before

initiating antibiotic therapy

Failure to confirm pregnancy

before initiating antibiotics.

l)Delay in diagnosis from failing

to order U/A and/or B-HCG
2)0rdering invasive tests t hat
will subject the patient to
discomfort or risk and add no
benefit to the patient care such
as cystoscopy
3)Pursuing alternative diagnoses
with tests such as laparoscopy for
PID

USMLEWORLD CCS - Ex lanat1on

CLOCK MANAGEMENT AND SEQUENCING

Ex am:

Focused physical exam (as ment ioned in "Scoring")

Order:

Beta HCG, qualitative

U/A

Clock:

Advance the clock to evaluate the laboratory results

Note the positive HCG; U/A is positive for nitrite, leukocyte esterase, bacteria, and leukocytes

Order:

Nitrofurantoin, oral, continuous

Urine culture
Prenatal vitamins, oral, continuous
Counseling (as mentioned in "Approach to the case")

location:

Change to home
Schedule an appointment in 2 weeks
Confirm move
Patient improves
Case ends

Final orders:

Urine culture

Primary diagnosis:

Uncomplicated acut e cystitis and pregnancy