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Genitourinary

Patient Case

 

AMA. is a 37-y o female that presents to you for a routine physical. She denies any complaints other than chronic plantar fasciitis; she is a long-distance runner and has qualified for the Olympic Marathon on several occasions.

Height 5’1″ Weight  130 lbs. BP 90/60, HR 50 Temp 98.1. 

Taking a multivitamin with Fe, plus an additional B12,/folate supplement. 

She eats mainly a plant-based diet but recently has added in fish to supplement her protein intake. G0P0. she relates she is not currently sexually active. 

AMA’s urinalysis is positive for 10 RBCs/hpf. All other labs are normal or negative. 

The physical exam is unremarkable.

 

 

(a) What additional Subjective information do you need/want, and why do you need/want it? 

 

(b) Your physical exam is unremarkable, and all initial diagnostic studies are normal or negative, what is the    presumptive diagnosis with ICD 10 code (also provide likely differentials); 

c) how would you counsel your patient; provide a rationale? 

 

(c) You see your patient back in 4-6 weeks and the hematuria persists, to whom do you refer your patient, and why? 

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