Differential Diagnosis

• Single most likely diagnosis
  • Urinary Tract Infection (UTI): The patient's symptoms of urinary frequency, gross hematuria, malaise, and mild dysuria, along with the presence of nitrite and yeast in the urine analysis, suggest a UTI. The resolution of symptoms after starting antibiotics further supports this diagnosis.
• Other Likely diagnoses
  • Kidney Stone (Nephrolithiasis): The patient's history of renal colic and nephrolithiasis, along with the recent episode of gross hematuria, suggests that a kidney stone may have passed, causing the symptoms.
  • Prostatitis: The patient's enlarged prostate gland (5.0x3.8 cm) and symptoms of urinary frequency and mild dysuria could be indicative of prostatitis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Sepsis: Although the patient's symptoms have resolved, the presence of nitrite and yeast in the urine analysis could indicate a more severe infection, and sepsis should be considered, especially if the patient's condition worsens.
  • Bladder Cancer: The patient's gross hematuria and scheduled cystoscopy suggest that bladder cancer should be considered, although it is less likely in a 28-year-old male.
• Rare diagnoses
  • Tuberculosis (TB) of the Urinary Tract: Although rare, TB of the urinary tract could present with similar symptoms, including hematuria and frequency.
  • Interstitial Cystitis: This condition could cause similar symptoms, including frequency and dysuria, although it is less likely in a male patient.

Applicable ICD10 codes

• N20.9: Calculus of kidney, unspecified
• N30.0: Acute cystitis
• N40.1: Benign prostatic hyperplasia with lower urinary tract symptoms
• R31.0: Gross hematuria
• R35: Dysuria
• Z85.46: Personal history of kidney stones
• Z87.39: Other personal history of diseases and conditions of the genitourinary system