Dominican college case narratives samples

Case Narrative #8

URINARY TRACT INFECTION

The following case study addresses the post hospitalization follow-up care I provided for a 28-year-old female who presented to the Outpatient clinic with complaints of dysuria and foul-smelling urine. She also complains of frequency to voiding, but only able to get out a few drops at a time. She has had 4/10 abdominal discomfort for the past 2 days, endorses lower back pain, and denies any hematuria with urination. She denies nausea/vomiting and denies having a fever. The patient’s primary insurance is Healthfirst. The case addresses the following doctoral competency objectives: 

Objective 7: Differential diagnostic evaluation of patients with undifferentiated conditions including rationale for impression and plan. 

Objective 8: Referral decisions, collaborative networking while maintaining primary responsibility for care, decision-making utilizing recommendations, patient follow-up and outcomes, including one consultation follow up. 

Chief Complaint:  History and Present Illness: The patient presents to the clinic for complaints of dysuria, foul smelling urine and abdominal pain for 2 days.  

Past Medical History:

History of Chlamydia at age 21 

Asthma 

Surgical:

Appendectomy at age 18 –no complications

Accidents, injuries, or hospitalizations:

None reported 

Psycho-social history: 

The patient lives at home with her husband. Has 3 children all alive and in good state of health. Currently, the patient is employed at the local school cafeteria.  She denies smoking, illicit drug use and alcohol.  

Allergies 

No known allergies to medications or foods.

No seasonal allergies

Health Care Maintenance:

Patient has refused all vaccines including influenza and COVID 19.  

Has not had recent Pap smear

Review of Systems 

General Health: The patient states she has dysuria, abdominal pain and foul smelling urine

Skin: Denies any pigment or color change. Denies any excessive dryness, itching, excessive bruising, rash, or lesion.

Head/Eyes/Ears/Nose/Throat: Denies headache, head injury, or dizziness 

Respiratory System: Denies shortness of breath or cough

Cardiovascular: Denies chest pain, palpitations or difficulty breathing with exertion.

Gastrointestinal: Denies nausea or loss of appetite. She endorsed lower abdominal pain 4/10 on wong pain scale

Genitourinary: Endorsed foul smelling urine, dysuria and frequent urination 

Physical Assessment 

Measurements: Height:  5’ 6”    Weight: 150lbs   BMI: 24.2   Temp: 99.7    Pulse:  96 B/P: 98/60  Sp02:  98%

Lungs: Clear bilaterally to auscultation.  

Heart: Regular rate and rhythm, S1, S2, without murmurs, rubs, or gallops.

Abdomen: Positive bowel sounds in all four quadrants

Neurologic: awake, alert, oriented to person, place, time and situation

Skin: Intact without lesions or rashes.  

Psych: Alert and cooperative; normal mood and affect; normal attention span and concentration.  

Lab Test: Done in office

Urine dip stick done in office and was positive for Nitrites. Indicative of UTI

Urine culture sent to lab to determine microorganism

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Differential diagnosis: (Objective 7) 

1. Urinary tract infection (N39.0)

2. Acute Pyelonephritis  (N10) 
3. Chlamydia (A74.9)
4. PID (N73.9)
5. Appendicitis (K35.2) 

  Assessment/Final Diagnosis with ICD 10 code:

1. Urinary tract infection (N39.0)

Urinary tract infection as the term suggest, refers to the invasion of the urinary tract which is comprised of the kidneys, ureter, urethra and the bladder. These components functions together to facilitate waste and excessive fluid removal which enables homeostasis of the body. The understanding of this concept was important in explaining the condition to the patient with specific indication of the symptoms which included urine positive for nitrite, lower abdominal pain, dysuria and foul-smelling urine (Bono & Reygaert, 2021). The presentations mentioned as the symptoms of urinary tract infections were all present on the patient hence, I considered urinary tract infection as the first diagnosis (Oxford level of evidence 2a). 

2. Acute Pyelonephritis (N10)

Acute nephritis affects similar organs of the urinary tract as urinary tract infection. It however affects the kidneys mostly, resulting in inflammation of the kidneys. The disease has a link with urinary tract infection in that; it can result as a result of an ascending urinary tract infection which spreads to all the renal system regions including the kidneys and the bladder (Belyayeva & Jeong, 2021). Similarly, the conditions are caused by bacteria which makes their presentations similar. The presentations include chills, dysuria and costovertebral angle tenderness. The similarity in symptoms among the two conditions makes it a perfect differential diagnosis in this case. (Oxford level of evidence 4).

3. Chlamydia (A74.9)

The condition is caused by bacteria chlamydia trachomatis and is sexually transmitted. If left untreated, the condition can spread to other parts of the body bringing about other complication. The major symptoms of chlamydia include discharge from the genital organs that is, vaginal discharge in women, and discharge from the penis. Other symptoms include painful intercourse, testicular pain and bleeding between periods in women (Páez-Canro et al., 2019). Despite the patient representing with a foul smelling urine and a burning sensation during urination, she had no discharge from the genitals which led to the decision of including the condition as a differential diagnosis. (Oxford level of evidence 2a)

4. Pelvic inflammatory disease (PID)

PID affects women only. It is closely linked to a sexually transmitted disease and often presents with lower abdominal pain, vaginal discharge and stomach pains (Curry et al., 2019). PID was considered in this case due to the noted lower back pain and the urinary tract infections. (Oxford level of evidence 2a)

Plan  

Start oral antibiotics for 7 days Bactrim DS

“Sulfamethoxazole and trimethoprim are the key components of Bactrim S which is an effective antibiotic medication against several bacterial infections (Fox et al., 2017)”

CEBM, Level 2a

Discuss increasing fluid intake to help with UTI. 

“Taking fluids especially water is likely tto help in the elimination of the bacteria from the urinary system” (Fasugba et al., 2020).

CEBM, Level 1a

Recommend the patient to take showers instead of baths   

The patient’s current condition, urine dip stick, and physical assessment has been discussed with the patient.  The treatment plan reviewed and all questions were answered accordingly. The patient has been educated on the importance of completing entire course of antibiotics, good hygiene and increasing her fluid intake. She was instructed to return to the clinic if her symptoms do not subside within 3-4 days and to report to the emergency room if abdominal pain worsens and if her urinary output decreased.  I referred the patient to the Gynecologist as she has not had a recent pap smear (Objective 8).   

Referrals and Outpatient Testing 

1. Gynecology 

“The gynecologists would provide further assessment and management of UTI related complications. According to Dason et al. (2011), the underlying cause of UTI is unknown, thus, further specialized investigation is necessary.” 

Medications

Drug	Mechanism of Action	Clinical Use	Side Effects
Bactrim DS one tab by mouth every 12 hours for 10 days	inhibits bacterial synthesis of dihydrofolic acid	treat a wide variety of bacterial infections	loss of appetite, headache, nausea, vomiting, and stomach pain
Albuterol HFA 2 puffs every six hours as needed	acts on beta-2 adrenergic receptors to relax the bronchial smooth muscle	Managing breathing related complications such as wheezing and shortness of breath	Nervousness or shakiness, headache, throat or nasal irritation, and muscle aches.

References

Bono, M. J., & Reygaert, W. C. (2021). Urinary Tract Infection. In StatPearls. StatPearls Publishing.

Belyayeva, M., & Jeong, J. M. (2021). Acute Pyelonephritis. In StatPearls. StatPearls Publishing.

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. American family physician, 100(6), 357–364. https://pubmed.ncbi.nlm.nih.gov/31524362/

Dason, S., Dason, J. T., & Kapoor, A. (2011). Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Canadian Urological Association journal = Journal de l'Association des urologues du Canada, 5(5), 316–322. https://doi.org/10.5489/cuaj.11214

Fox, M. T., Melia, M. T., Same, R. G., Conley, A. T., & Tamma, P. D. (2017). A Seven-Day Course of TMP-SMX May Be as Effective as a Seven-Day Course of Ciprofloxacin for the Treatment of Pyelonephritis. The American journal of medicine, 130(7), 842–845. https://doi.org/10.1016/j.amjmed.2017.01.025

Fasugba, O., Mitchell, B. G., McInnes, E., Koerner, J., Cheng, A. C., Cheng, H., & Middleton, S. (2020). Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: a systematic review. The Journal of hospital infection, 104(1), 68–77. https://doi.org/10.1016/j.jhin.2019.08.016

Páez-Canro, C., Alzate, J. P., González, L. M., Rubio-Romero, J. A., Lethaby, A., & Gaitán, H. G. (2019). Antibiotics for treating urogenital Chlamydia trachomatis infection in men and non-pregnant women. The Cochrane database of systematic reviews, 1(1), CD010871. https://doi.org/10.1002/14651858.CD010871.pub2