A 25-year-old woman presents for care and reports a 2-day history of burning with urination, urinary frequency, and feeling as though she is not emptying her bladder completely. She is sexually active with the same male partner for the past 4 months and is using a progesterone IUD for contraception.
Her past medical and surgical histories are negative, and she has no known drug allergies (NKDA).
She denies fever, chills, vaginal discharge, concerns about the IUD, or previous urinary infections or problems.
What would you do for her during today’s visit? Assessment, labs, etc.
Based on the patient’s clinical presentation, what is the clinical diagnosis chosen for this visit?
Please answer using the SOAP format