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working diagnosis/potential diagnosis

LN is a twenty-six-year-old married woman who presents at the clinic with symptoms of dysuria, frequency, and urgency. Further history yields two days of these symptoms but no fever, chills, or flank pain. She describes a burning discomfort during and immediately following urination and feeling the need to void every half hour. There is no vaginal discharge, itching, or odor. She is not using birth control at this time. She requests “a urine culture and some sulfa pills.” When asked to explain, she says she has had many “bladder infections” over the past three years and “sulfa pills usually work.” She was evaluated approximately five years ago with an IV pyelography and cystogram, and “nothing was wrong.” All her vital signs are normal. Answer the following questions:

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  • What additional information would you like to collect?
  • What is your working diagnosis?
  • What are the contributing factors to this potential diagnosis?
  • What treatment would you implement and why?
  • What type of follow-up would you recommend?

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