Case Studies: UTI

Kimberly Moriarty
Case Studies: UTI (70 total points)
Beccie is a 25 year old woman who presents with a “48 hour history of needing to
urinate frequently, and it hurts when she does”. She also thinks she may have seen
blood in her urine but wasn’t sure. (20 total points)
1. What other information about her personal history would you like to know? (4 points)
a.last menstrual period
b.methods of birth control
c.recent sexual activity
d.history of STIs
2. List all of the signs and symptoms of UTI you would need to ask the patient about to
be able to diagnose a simple UTI. ( 5 points)
Back pain
Beccie reveals the following information: She has never had a UTI before either as an
adult or a child. She has no back or flank pain as well as no vaginal irritation or
discharge. She takes an oral contraceptive pill and tells you it is extremely unlikely she is
pregnant as she had her period last week. She takes no other medications. You take her
temperature and it is 36.8ºC.
3. Would you order or perform any tests today? If so, what and why? ( 3 points)
Urine analysis and culture with sensitivity.
She is presenting with the typical symptoms of a urinary tract infection. Would
recommend a STI screening as well to be done with the urine. These could also be
symptoms of a STI.
4. Which antibiotic (medication, dose, frequency and duration would you prescribe) and
why? (5 points)
Bactrim 160/800 1 tab for three days
Standard therapy. More compliance with shorter courses.
5. What additional instructions would you include in addition to antibiotic instructions?
(3 points)
Urination pre/post intercourse
Drink plenty of fluids
Urinate frequently
Wear loose fitting underwear, cotton
Lisa, age 4, is brought in to your office by her mother with a 2-day history of fever
and irritability. Her mother has noticed that she has been going to the toilet more
often and complaining of pain when she passes urine. Lisa has not been eating well
but has had no episodes of vomiting. She has had no previous urinary frequency or
dysuria that her mother can remember and has no relevant medical history. She is
not taking any medications and has no known allergies. On examination her pulse
rate is 100 beats per minute and temperature is 37.8°C. She weighs 17 kg and is 102
cm. On palpation her abdomen is soft and her bladder is not palpable. She has no
suprapubic tenderness and does not complain of flank pain on examination. There is
no evidence of vulvitis. A urinalysis was positive for leukocytes and nitrites.
Midstream urine (MSU) was sent for culture and sensitivity. (15 points)
1. What would be your initial step in drug management (if any) before the MSU result is
available? If you do decide to prescribe, specify the drug, dose, frequency and
duration/course of therapy. (5 points)
Trimethoprim (6-12 mg/kg)-sulfamethoxazole (30-60mg/kg)
50/400 mg bid for 7 days
2. What additional advice would you provide? (3 points)
Increase fluids, prevent constipation, cranberry juice
Return in 3 days if not better, or with a temperature
The MSU result is consistent with a UTI. Pure growth of Escherichia coli is
reported, with sensitivity to trimethoprim, trimethoprim+sulfamethoxazole,
cephalexin, amoxycillin+clavulanate, and gentamicin.
3. Would you continue the same antibiotic, change antibiotic therapy or discontinue
antibiotics after the initial course of antibiotic therapy is complete? If you would not
discontinue antibiotics, please indicate what you would prescribe, including drug, dose,
frequency, and duration if you change medications. If you decide to discontinue the
antibiotics, what is your rationale? (4 points)
Continue current dosage and course. Extend course if unable to return in a week for
ultrasound and VCUG.
4. What further investigation/s (if any) would you order and why? (3 points)
Renal and bladder ultrasound. This would check for gross deformities in the structures of
the organs.
Voiding cystourethrogram. This diagnoses vesicourethral reflux.
If she has any abnormalities, they must be fixed to prevent further complications of
scarring and damage to the kidneys.
You saw LK three days ago or a return OB visit. She is a 19 year old G1P0000 at 28
weeks with a history of UTI 10 weeks ago. At this visit you followed your clinical
guidelines for women with a history of UTI in pregnancy and ordered a clean catch,
midstream UA with a culture and sensitivity. She has no symptoms of UTI. Here are
the results of your tests: (20 points)
Nitrates: neg
LCE: pos
WBCs 10-12
RBCs neg
Bact: mod
epithelial: mod
Culture: 100,000 mixed staph epidermis and lactobacillus
Interpret these results: (5 points)
Nitrates-neg: normal finding
LCE-pos:abnormal finding. May indicate infection urinary tract. Also found in vaginal
WBCs 10-12:normally low (0-4). Indicated some infection/inflammation of the urinary
tract. Also can be elevated with vaginal secretions
Bact: Mod:normally negative. Could be an indicator of infection
Epithelial: Mod: usually none. Means the specimen could be contaminated with skin flora
Culture-Mixed: indicated possible contamination. Need another sample
Does LK have another UTI? (1 point)
Why or why not? (2 points)
No signs and symptoms. Nothing in her UA that is wholly convincing of an infection.
Would like another sample to retest.
What would you do? If you are prescribing, state the name of the drug, dose, frequency
and duration. (4 points)
Watch and see. Tell her to increase fluid intake. Return or call is she develops symptoms
of a UTI. Educate about pregnancy and increased risk of UTIs.
Does pregnancy affect the risk of UTI? If so, why or why not? (4 points)
Yes. It increases the risk of developing a UTI. In pregnancy the woman’s urethra dilates,
decreases urethral tone, decrease bladder tone and bladder volume increases. All of these
things increase the chances of developing a UTI.
Clinically, how would you differentiate acute pyelonephritis from an uncomplicated
UTI? (4 points)
Pyelo is an acute onset of chills, fever, flank pain, malaise and CVA tenderness. These
patients also present very VERY sickly looking, and have extremely high temps (I’ve
seen 104-105 before).
A UTI is acute onset as well, not as severe. Usually does not present with a fever, just
the usual frequency and pain with urination.
Provide at least three differential diagnosis for EACH of the symptoms of UTI that
you identified in this case study, question 2. (20 points)
Dysuria: STI, urethritis, vaginitis, urethral trauma
Frequency: dysfunctional voiding, urethral syndrome, increased fluid intake, STI,
Hematuria: trauma, interstitial cystitis, kidney stones, cancer
Back Pain: kidney stones, pulled muscle, PID, appendicitis