The patient, a 29-year-old female, presented with acute onset of hypogastric pain, urinary frequency and dysuria and was found to have direct tenderness over the hypogastric area on examination. Differential diagnoses considered included acute uncomplicated cystitis and recurrent UTI, which were felt to be most likely given the patient's history of recurrent UTIs and presentation. She was admitted for intravenous antibiotics and monitoring.
The patient, a 29-year-old female, presented with acute onset of hypogastric pain, urinary frequency and dysuria and was found to have direct tenderness over the hypogastric area on examination. Differential diagnoses considered included acute uncomplicated cystitis and recurrent UTI, which were felt to be most likely given the patient's history of recurrent UTIs and presentation. She was admitted for intravenous antibiotics and monitoring.
The patient, a 29-year-old female, presented with acute onset of hypogastric pain, urinary frequency and dysuria and was found to have direct tenderness over the hypogastric area on examination. Differential diagnoses considered included acute uncomplicated cystitis and recurrent UTI, which were felt to be most likely given the patient's history of recurrent UTIs and presentation. She was admitted for intravenous antibiotics and monitoring.
The patient, a 29-year-old female, presented with acute onset of hypogastric pain, urinary frequency and dysuria and was found to have direct tenderness over the hypogastric area on examination. Differential diagnoses considered included acute uncomplicated cystitis and recurrent UTI, which were felt to be most likely given the patient's history of recurrent UTIs and presentation. She was admitted for intravenous antibiotics and monitoring.
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CASE Presentation
PGI DELA TORRE, RALPH DALE S.
General Data K.M 29/F Born on October 8, 1993 at Cebu City Filipino Roman Catholic Currently Residing at M-131 Purok Mazari, Inayagan, Naga Was admitted on November 20, 2022 for the first time at South General Hospital Chief Complaint
Hypogastric Pain History of Present Illness
1 day prior to admission, patient noted sudden
onset of intermittent hypogastric pain, burning in character, with a pain score of 8/10 which radiates to the lower back. Patient did not take any medications. No fever, no nausea or vomiting No consultation was done. History of Present Illness
Morning prior to admission, condition
persisted now with urinary frequency and dysuria hence the consult. Patient was subsequently advised for admission Past Medical History
Childhood illnesses include measles
Complete childhood immunizations from local barangay
health center
Medical Illnesses: Recurrent UTI
Past Surgeries: Primary Cesarean Section 2017
No injuries, accidents or prior hospitalizations
Past Medical History OB/Gyne: G1P1 (1001)
Menarche: 12 years old
Subsequent menses: regular, consumes 2-3 pads per day, lasting for 3-5 days
Sexual History
Coitarche: 24 years old
Sexual partner: 1
No contraceptive use
No dyspareunia Personal and Social History Patient is a housewife non-alcoholic and non-smoker No history of illicit drug use No known allergies to food or medications Living in own house with adequate water and electric supply with regular garbage disposal Family History Non-hypertensive Non-Diabetic Non-asthmatic Review of Systems General. (-) weight change, weakness, fatigue Skin. Rashes, lumps, sores, itching, color change, changes in hair or nails Head, Eves, Ears, Nose, Throat (HEENT) Head. Headache, head injury, dizziness, light-headedness Eyes. Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts Ears. Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids Nose and sinuses. Frequent colds, nasal stuffiness, discharge, or itching hay fever, nosebleeds, sinus trouble Throat. Condition of teeth, gums, bleeding gums, dentures, if any and how they fit, last dental examination, sore tongue, dry tongue, frequent sore throats, hoarseness Neck. Lumps, "swollen glands", goiter, pain or stiffness in the neck Review of Systems Respiratory. Cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray, asthma, pneumonia, TB Cardiovascular. Heart trouble, high BP, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema Gastrointestinal. Trouble swallowing, heartburn, loss of appetite, hematemesis, bowel movements, change in bowel habits, rectal bleeding or black/tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, excessive belching or passing of gas, jaundice, liver or gallbladder trouble, hepatitis Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling Genital. Masses, lesions, vaginal discharges, dyspareunia Review of Systems Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected joints, muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness or limitation in motion or activity, duration & any history of trauma Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or "pins and needles", tremors or other involuntary movements Hematologic. Anemia, easy bruising or bleeding, past transfusions and or transfusion reactions Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant Physical Examination General Survey: Awake, conscious and not in respiratory distress Vital Signs: BP: 110/70 Temperature: 36.6C HR: 91 RR: 21 Height: 160cm Weight: 60kg BMI: 23.4 – Normal Physical Examination Skin: no rashes, no bruises, no lesions, warm, good turgor and mobility
Urinary tract infection, recurrent Basis History
Acute Uncomplicated Cystitis is suspected in premenopausal non-
pregnant women presenting with acute onset of dysuria, frequency; and without vaginal discharge
Recurrent UTI is diagnosed when a healthy non-pregnant woman
with no known urinary tract abnormalities has 2 or more episodes of acute uncomplicated cystitis in a 6-month period Basis
Between 1 year and 50 years of age, UTI and recurrent UTI
are predominantly diseases of females
As many as 50-80% of women in the general population
acquire atleast one UTI during their lifetime – uncomplicated cystitis in most cases Differential Diagnosis Rule in Rule out Nephrolithiasis (+) Flank pain (-) hematuria (+) dysuria Ruled out through labs (+) urinary frequency Pelvic Inflammatory (+) hypogastric pain (-) fever Disease (+) pain radiating to the (-) multiple sexual back partners (+) direct hypogastric Ruled out through tenderness transvaginal ultrasound (+) dysuria Acute Appendicitis (+) abdominal pain (-) Rovsing’s sign (+) direct hypogastric (-) Obturator sign tenderness (-) Psoas sign Course in the Wards Hospital Day 0 (11/20/22) S/O A P
Warm skin, good turgor Acute Uncomplicated - Patient admitted
and mobility, pink Cystitis - Vital signs monitoring palpebral conjunctiva Recurrent UTI Q4h Hypogastric pain(PS 8/10) - Patient placed on DAT and tenderness - Patient for diagnostic tests Awake, NIRD - IVF: PNSS 1L at T: 36.6C 80cc/hr P: 91 - Start R: 21 Cefepime/Tazobactam BP: 110/70 2g IV infusion as loading dose then 1 gram/125mg IV q 12 hours Course in the Wards Hospital Day 0 (11/20/22) S/O A P
Warm skin, good turgor Acute Uncomplicated - Pantoprazole
Color STRAW Nitrite NEGATIVE Transparency CLEAR Protein NEGATIVE Chemical Examination Urobilinogen 0.2 pH 6.5 Ketone NEGATIVE Sp. Gravity 1.005 Bilirubin NEGATIVE Leukocytes NEGATIVE MICROSCOPIC EXAMINATION Blood NEGATIVE Pus Cells 32.5 0-5/HPF Red Cells 0.6 0-3/HPF Epithelial 0.2 0-3/HPF Cells Bacteria 0.6 0-50/HPF Cast 2.6 0-3/HPF Course in the Wards Hospital Day 1 (11/21/22) S/O A P
Warm skin, good turgor Acute Uncomplicated -Patient for diagnostic
and mobility, pink Cystitis tests: Urine Culture and palpebral conjunctiva Recurrent UTI Sensitivity and Repeat Hypogastric pain(PS = Urinalysis 3/10) Medications: 1.) Cefepime + Awake, NIRD Tazobactam 1gm/125mg T: 36.4C q12h IV infusion P: 89 2.) Pantoprazole 40mg OD R: 21 PO BP: 110/70
UO: 2.1cc/kg/hr Labs
Urine Culture and Sensitivity (11/21/22)
MORE THAN 100,000 COLONIES OF GRAM NEGATIVE BACILLI PER ML OF URINE WAS ISOLATED Labs KUB (11/21/22) Unremarkable kidneys, ureters and bladder Course in the Wards Hospital Day 2 (11/22/22) S/O A P
Warm skin, good turgor Acute Pyelonephritis -Patient for diagnostic
and mobility, pink (E.coli isolate) tests: Repeat Urinalysis palpebral conjunctiva and follow up on urine sensitivity results Awake, NIRD Medications: T: 36.4C 1.) Cefepime + P: 89 Tazobactam 1gm/125mg R: 21 q12h IV infusion BP: 110/70
UO: 2.4cc/kg/hr Labs Urinalysis 11/22/2022
Macroscopic Examination Sugar NEGATIVE
Color YELLOW Nitrite NEGATIVE Transparency CLEAR Protein NEGATIVE Chemical Examination Urobilinogen 0.2 pH 6.5 Ketone NEGATIVE Sp. Gravity 1.005 Bilirubin NEGATIVE Leukocytes NEGATIVE MICROSCOPIC EXAMINATION Blood TRACE Pus Cells 0.9 0-5/HPF Red Cells 4.2 0-3/HPF Epithelial 0.4 0-3/HPF Cells Bacteria 3.4 0-50/HPF Cast 0.3 0-3/HPF Labs Urine Culture and Sensitivity (11/22/22) Course in the Wards Hospital Day 3 (11/23/22) S/O A P
Warm skin, good turgor Acute Pyelonephritis -Patient for diagnostic
and mobility, pink (E.coli isolate) - improved tests: Repeat Urinalysis palpebral conjunctiva -Terminate IVF -may go home Awake, NIRD Medications: T: 36.4C 1.) Cefepime + P: 89 Tazobactam 1gm/125mg R: 21 q12h IV infusion BP: 110/70 Medications to continue: UO: 2.2cc/kg/hr 1.) Coamoxiclav 620mg/tab take 1 tab 3x daily for 5 days Labs Urinalysis 11/23/2022
Macroscopic Examination Sugar NEGATIVE
Color LIGHT YELLOW Nitrite NEGATIVE Transparency CLEAR Protein NEGATIVE Chemical Examination Urobilinogen 0.2 pH 7.5 Ketone NEGATIVE Sp. Gravity 1.010 Bilirubin NEGATIVE Leukocytes NEGATIVE MICROSCOPIC EXAMINATION Blood NEGATIVE Pus Cells 0.4 0-5/HPF Red Cells 1.4 0-3/HPF Epithelial 0.1 0-3/HPF Cells Bacteria 0.7 0-50/HPF Cast 0.0 0-3/HPF Diagnosis
Acute Pyelonephritis (Escherichia coli isolate)
Management
Maintenance Fluids: PNSS 1L at 80cc/hr
Medications: Cefepime/Tazobactam 2g IV infusion as loading dose then 1gram/125mg IV q 12hours Pantoprazole 40mg/tab 1 tablet orally once daily Tramadol + Paracetamol 37.5/325mg tab 1 tab orally 3x daily as needed for pain PS > 4/10 Coamoxiclav 625mg/tab 3x daily for 5 days DISCUSSION Urinary Tract Infection Epidemiology
Except among infants and elderly, UTI occurs far more
commonly in females than males
Between 1 year and 50 years of age, UTI and recurrent
UTI are predominantly diseases of females
As many as 50-80% of women in the general population
acquire at least one UTI during their lifetime Urinary Tract Infection
Etiology
E.coli accounts for 75-90% of isolates;
Staphylococcus saprophyticus for 5-15%; and Klebsiella, Proteus, Enterococcus, and Citrobacter species for 5-10% Pathogenesis Diagnostic Approach THANK YOU!
