PART 1: PICK ONE OF THE THREE (3) CASES
Review the urinary infectious cases and determine the most likely cause, including pathogen and mode of transmission. Discuss data that supports your decision and treatment strategies.
Case 1
A 50-year-old woman presented complaining of burning sensation when urinating and feeling like she has to go every hour for the last day. She denies fever and suprapubic or back pain.
- Past medical history: dyslipidemia and hypertension.
- Medications: atorvastatin.
- Allergies: sulfa.
- Physical examination: temperature 98.5°F; pulse 80 beats per minute; respirations 18 per minute; blood pressure 110/66 mmHg; examination unremarkable; no suprapubic or costovertebral angle tenderness; urine dipstick reveals moderate leukocytes and positive nitrites, with all other values within normal limits.
- What is the most likely diagnosis and pathogen causing this disorder and mode of transmission? Discuss data that support your decision.
- What diagnostic test, if any, should be done?
- What are diagnostic test findings would support your diagnosis?
- Develop a treatment plan for this patient.
Case 2
A 65-year-old woman with no urinary system complaints had a routine urinalysis with the following results:
- What is the most likely diagnosis and pathogen causing this disorder and mode of transmission? Discuss data that support your decision.
- What diagnostic test, if any, should be done? Develop a treatment plan for this patient.
Case 3
A 45-year-old woman is complaining of urgency and dysuria for the past 2 days. Yesterday, she started getting chills, feels she is getting a fever, and her back hurts.
- Past medical history: UTI 1 year ago.
- Medications: none.
- Allergies: no known drug allergy (NKDA).
- Physical examination: temperature 100°F, pulse 86 beats per minute; respirations 18 per minute; blood pressure 110/70 mmHg; positive costovertebral angle and suprapubic tenderness, otherwise unremarkable; urine dipstick reveals positive leukocytes but negative for nitrites and blood.
- What is the most likely diagnosis and pathogen causing this disorder and mode of transmission?
- Discuss data that support your decision.
- What diagnostic test, if any, should be done? What diagnostic test findings would support your diagnosis?
- Develop a treatment plan for this patient.
Part 2: Complete all
Review the following case and urinalysis report.
A 46-year-old woman is asymptomatic and has a routine urinalysis as part of her annual physical. The urinalysis with microscopy report is as follows:
- Describe the urinalysis findings and determine possible reasons for the findings and follow-up, if necessary.
Part 3: Pick one of the three (3) cases
Hematuria is common and can be due to benign conditions (e.g., strenuous exercise) or serious disorders (e.g., renal cell carcinoma). Review these cases and determine the most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Case 1
A 50-year-old White man is complaining of left-sided flank pain that started about 3 hours ago. He describes the pain as sharp and intermittent. He notes that his urine is a bit darker, but he denies seeing blood. The pain started after he finished mowing a client’s lawn (he is a gardener). He denies dysuria, urgency, or fever.
- Past medical history: gout.
- Medications: allopurinol 100 mg orally every day.
- Allergies: no known drug allergies (NKDA).
- Social history: denies smoking, alcohol use, or drug misuse.
- Physical examination: temperature 98.5°F; pulse 96 beats per minute; respirations 20 per minute; blood pressure 138/88 mmHg.
- General: anxious, holding left side, and moving around; otherwise, examination is unremarkable.
- Urinalysis: positive for blood with 15 RBCs per HPF; remainder unremarkable.
- Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Case 2
An 8-year-old Black girl is complaining of burning when urinating for the past day. She reports wetting herself at school because she was unable to hold it until she was able to get to the bathroom. When she toileted, she voided only small amounts. She denies fever, back, or suprapubic pain. The child is accompanied by her mother.
- No past medical history or medications.
- Allergies: penicillin (hives).
- Vaccines: up to date.
- Physical examination: vital signs and examination are within normal limits.
- Urine dipstick: positive for leukocytes, nitrites, and blood.
- Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Case 3
A 68-year-old White man is concerned because he thinks he is peeing blood. He noticed it about 1 month ago, and he thought it was related to sex as he noticed it right after intercourse. However, he has had two other episodes within the past two weeks not related to sexual intercourse. He denies fever, dysuria, frequency, abdominal, back, or pelvic pain. He states he used to have a weak stream and have to urinate at night, but these symptoms have improved since starting finasteride (5?-reductase inhibitor).
- Past medical history: BPH.
- Medications: finasteride.
- Allergies: no known drug allergy (NKDA).
- Social history: has smoked 1 pack of cigarettes per day for the past 40 years; drinks two to three beers on the weekends.
- Physical examination: body mass index 32; vital signs and examination are within normal limits.
- Urinalysis with microscopic evaluation: positive for blood with 40 RBCs/HPF; no casts or dysmorphic cells noted.
- Discuss most likely cause of the hematuria. Discuss data that supports your decision as well as diagnostic and treatment strategies.
Part 4: Complete
A 13-year-old boy presented to the clinic complaining of a sore throat that persisted for 2 days. After those 2 days, he developed fever, nausea, and malaise. A throat culture revealed the presence of group A beta-hemolytic streptococci, and the child was started on antibiotic therapy. The child’s symptoms gradually improved, but approximately 2 weeks later, he returned to the clinic because the fever, nausea, and malaise returned. He became tachypneic and short of breath. The mother noted that his eyes were puffy, his ankles were swollen, and his urine was dark and cloudy.
On examination, the child’s blood pressure was 148/100 mmHg; his pulse 122 beats per minute; and his respirations were 35 per minute. Orbital and ankle edema were present. Crackles were auscultated bilaterally. No heart murmurs were found. Slight tenderness to percussion over the flank areas was noted.
A chest X-ray showed evidence of congestion and edema in the lungs. The patient’s hematocrit was 37%, and his WBC count was 11,200/mm3. Blood urea nitrogen was 48 mg/dL (normal is less than 20 mg/dL). Urinalysis results showed that the patient’s protein was 2+ (24-hour excretion was 0.8 g), specific gravity was 1.012, and there were moderate amounts of RBCs and WBCs in the urine. Serum albumin was 4.1 g/dL (normal is 3.5–4.5).
- Which evidence supports the conclusion that this patient has a kidney disease?
- Which clinical pattern of kidney disease does this patient have? Explain the symptoms.
- Which morphologic changes would you expect in the kidney?
- What is the prognosis?
- What are the possible short- and long-term complications of this disease?
- Is it necessary to hospitalize the patient?
Expert Solution Preview
Introduction:
In this assignment, we will review various urinary infectious and hematuria cases. For each case, we will discuss the most likely diagnosis, pathogen causing the disorder, mode of transmission, diagnostic tests, and treatment strategies. Additionally, we will analyze a urinalysis report and determine possible reasons for the findings. Finally, we will assess a case of kidney disease and analyze the evidence, clinical pattern, symptoms, morphologic changes, prognosis, complications, and the need for hospitalization.
Part 1: Case Review
Case 1:
The most likely diagnosis for this patient is a urinary tract infection (UTI) caused by a bacterial pathogen. The presence of a burning sensation during urination, increased frequency, moderate leukocytes, and positive nitrites on urine dipstick support this diagnosis. The absence of fever and suprapubic or back pain suggests that the infection has not spread to the kidneys.
To confirm the diagnosis, a urine culture should be performed to identify the specific pathogen causing the infection. The findings of significant bacterial growth would further substantiate the diagnosis.
The treatment plan for this patient would involve initiating empirical antibiotic therapy based on the most common pathogens causing UTIs. Since the patient is allergic to sulfa drugs, an alternative antibiotic such as a fluoroquinolone or nitrofurantoin could be prescribed.
Case 2:
The most likely diagnosis for this patient is asymptomatic bacteriuria, which is the presence of bacteria in the urine without any apparent symptoms. The positive leukocytes, nitrites, and blood on the urine dipstick suggest an underlying infection; however, the patient remains asymptomatic.
A urine culture should be done to confirm the presence of bacteria and identify the specific pathogen causing the infection. Antibiotic treatment may not be necessary unless the patient develops symptoms or complications.
Case 3:
The most likely diagnosis for this patient is acute pyelonephritis, which is a bacterial infection of the kidneys. The presence of urgency, dysuria, fever, and back pain indicate an upper urinary tract infection. The positive leukocytes on urine dipstick further support this diagnosis.
To confirm the diagnosis, a urine culture should be performed to identify the specific pathogen causing the infection. Additionally, imaging studies such as a renal ultrasound or CT scan may be required to assess the extent of kidney involvement.
Treatment for acute pyelonephritis involves hospitalization and intravenous antibiotics. Initial empiric therapy should cover common gram-negative pathogens, such as Escherichia coli, which is the most common cause of this condition.
Part 2:
The urinalysis findings in this case indicate the presence of proteinuria, as evidenced by 2+ protein on the dipstick and an elevated 24-hour protein excretion of 0.8g. A specific gravity of 1.012 suggests dilute urine. Moderate amounts of RBCs and WBCs are also present.
These findings raise concerns about possible kidney disease, specifically glomerular injury leading to proteinuria and hematuria. Further evaluation, including renal function tests, imaging studies, and a kidney biopsy, may be necessary to determine the underlying cause and establish an appropriate treatment plan.
Part 3: Hematuria Review
Case 1:
The most likely cause of hematuria in this patient is renal calculi (kidney stones). The sharp, intermittent flank pain, dark urine, and positive blood on urinalysis support this diagnosis. The physical stress of mowing the lawn may have triggered the passage of a stone, leading to hematuria.
Diagnostic tests such as a CT scan or ultrasound can confirm the presence of renal calculi. Treatment strategies for this patient involve pain management, hydration, and potentially, urologic intervention for stone removal.
Case 2:
The most likely cause of hematuria in this patient is urinary tract infection (UTI) with cystitis. The burning sensation during urination, urinary frequency, and positive leukocytes, nitrites, and blood on urinalysis support this diagnosis. The inability to hold urine may have contributed to the development of cystitis.
The diagnosis of UTI with cystitis can be confirmed by a urine culture to identify the specific pathogen causing the infection. Antibiotic therapy will be necessary to treat the underlying infection.
Case 3:
The most likely cause of hematuria in this patient is benign prostatic hyperplasia (BPH), which is a noncancerous enlargement of the prostate gland. The weak stream, nocturia, and recent episodes of hematuria following intercourse suggest BPH as the cause.
Although BPH is not directly responsible for hematuria, it can lead to bladder outlet obstruction, urinary stasis, and subsequent UTI, resulting in hematuria. Treatment options for this patient may include medication to relax the prostate or surgical intervention, depending on the severity of symptoms.
Part 4:
The evidence supporting the conclusion of kidney disease in this patient includes the presence of proteinuria (2+ on dipstick, 0.8g/24-hour excretion), elevated blood pressure (148/100 mmHg), edema (orbital and ankle), tachypnea, dark and cloudy urine, and abnormal renal function tests (elevated blood urea nitrogen and abnormal urinalysis findings).
The clinical pattern of kidney disease in this patient suggests glomerular disease, specifically nephrotic syndrome. Symptoms such as edema, proteinuria, and abnormal renal function tests are consistent with this pattern.
Morphologic changes in the kidney associated with glomerular disease may include thickening of the glomerular basement membrane, effacement of podocyte foot processes, and mesangial cell proliferation.
The prognosis for this patient depends on the underlying cause of the kidney disease. Prompt and appropriate treatment can help manage symptoms, slow disease progression, and improve long-term outcomes. Possible short-term complications include acute kidney injury and infection, while long-term complications may involve chronic kidney disease and end-stage renal disease.
Based on the severity of symptoms and clinical findings, hospitalization may be necessary for this patient to optimize management and evaluate the need for further interventions such as renal biopsy or initiation of immunosuppressive therapy.
Note: The answers provided above are based on hypothetical scenarios and should not substitute for professional medical advice or clinical decision-making.
