Case #11

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If you have completed case K, this is a review. Completion of this case will not be counted toward your assignment.

Chief Complaint

 

MP, a 35 year old African American female, presents to your office complaining of pain when she urinates. She is a divorced mother of three children ages 3, 5, and 9. She admits to having multiple sexual partners. She has not used any form of birth control since undergoing tubal ligation after the birth of her last child. She is not sure when her last menstrual period was because her menses have always been irregular. She thinks it was 6 weeks ago. Other than a recent URI, she states that she has been in good health. She has no other complaints.

 

  1. What is the differential for pain with urination?

Medical History

Upon further questioning you learn that MP does have mild pelvic pain. She also says that she feels like she "always has to go." She has been waking up 4-5 times at night to urinate for the last two nights. Although she has not taken her temperature, she has felt warm now and then over the past week but she dismisses this as part of her recent cold symptoms. She denies blood in her urine, chills, or an increased sense of urgency to urinate. She has never had a urinary tract infection. She admits that she has been feeling fatigued and run down lately. Her job is becomingly increasingly stressful as she takes on more responsibility. When asked about her sexual history, she states that since the divorce she has been seeing a few guys she met in local clubs. She refers to this as "sewing her wild oats." She says she married and had children at such a young age that she missed out on a lot of the experiences other women her age have already enjoyed. She loves her children but finds them overwhelming when they "act like little devils."
  1. What important questions should you ask given the chief complaint of dysuria?
  2. How do age and gender alter your differential for dysuria?
Further questioning of MP reveals the following:

Past medical history:
Asthma, allergic rhinitis
Past Surgical History:
Appendectomy age 13.
Tubal ligation after the birth of her last child.

Medications:
Albuterol inhaler and Claritin, as often as she can get samples from the city clinic

Social History:
She works full time as a checker at the local grocery store. Only recently has she begun receiving health insurance benefits. She has not had regular annual gynecological exams or received any consistent health. She drinks 2-3 beers per day, usually more on the weekends to help her deal with the stress of her children. She denies tobacco or illicit drug use.

Family History:
Mother has diabetes type 2 and hypertension.
Father died last year of an MI at age 60.
 
  1. What is your preliminary diagnosis?
  2. What would the presence of hematuria suggest?
  3. What could frequency and urgency in the absence of dysuria indicate?
  4. What could pyuria in the presence of fever suggest?

Physical Examination

Vitals: Temp 99.0, Pulse 82, BP 127/84, Resp 16/min

HEENT: Head normocephalic. PERRL. EOMI. Oropharynx and TMs clear.

Neck: Some nodal enlargement in the anterior cervical chain. Non-tender.

CV: S1, S2, RRR. No murmurs, rubs, or gallops appreciated.

Chest: Good air exchange. Slight expiratory wheezes over upper lung fields. No crackles. No CVA tenderness.

Abdomen: +BS. soft, ND. Diffuse lower quadrant tenderness. Marked suprapubic tenderness. No rebound or guarding.

Extremities: Peripheral pulses strong and equal bilaterally. DTRs 2+ upper and lower extremities.
Rectal: not performed

Gynecological: Normal external genitalia without lesions. Cervix and vaginal wall appeared normal. No bacteria or fungus were seen on KOH prep and wet mount. GC and chlamydia cultures sent. Bimanual exam shows normal size uterus, no cervical motion tenderness, and no adnexal masses or tenderness.

  1. When is a vaginal examination indicated in a patient presenting with dysuria?
  2. What laboratory tests do you want to order?
  3. What are the components of a full urinalysis?
  4. When should a microscopic examination be performed?
  5. How should a urine specimen be collected?
  6. When should a urine culture be obtained?
  7. When should a patient be referred to a urologist?

Test Results

A dipstick analysis is performed on MP in your office. The results are:
  • 2+ leukocyte esterase
  • 1+ nitrites
  • pH 7.4
  • negative blood
  • ketones
  • glucose
  • protein
  • bilirubin

No further tests are performed.
 
  1. What is your final diagnosis?
  2. Who is most at risk for UTI's?
  3. What are some markers indicating a UTI may be more serious or follow a complicated course?
  4. What are the most common pathogens causing UTI's?
  5. How are UTI's most commonly treated?
  6. Why do recurrent UTI's occur and how are they treated?
  7. Is resistance a problem in treating UTI's?
  8. What can MP do to prevent future UTI's?

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