Having hard time urinating

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Lilly is a 32-year-old female who presents today with "having a hard time urinating." She reports burning on urination, urinary frequency, and pain, and difficulty urinating. She has been experiencing these symptoms for the past 3 days. She denies vaginal discharge or bleeding, nausea or fever. She increased her fluid intake over the last 3 days and added cranberry juice but the symptoms have not improved. She reports having a UTI one year ago and was treated with an antibiotic, but she can't recall which one. She is married, has 3 children, has no known allergies, and currently takes no medications. On exam the patient appears in no distress, Temp 99, HEENT unremarkable, abdomen soft, non-tender, + bowel sounds in all 4 quadrants, GYN, no lesions, discharge, or cervical motion tenderness. Cervix normal.

The results of her urine specimen are: Ketones negative, Protein trace, Nitrite trace, RBC negative, Bacteria 5+.

Based on the symptoms and the urine specimen results what is your diagnosis and treatment plan?

Reference no: EM133881662

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