Urinary Tract Infection in Pediatrics

Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and negative information.
Would there be any other information you would want to obtain?
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion.

 

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C.C. Burning with urination, fever, N/V

HPI:16y.o. F presented to Clinic with grandfather for burning with urination that she began three days ago. She noticed that she was going to the bathroom more than normal. She recalls normal urinary frequency as four times daily, but for the past three days she has felt the urge to go to the bathroom six to eight times daily and has not been able to produce urine every time. She has also experienced increased burning during urination when she is able to produce urine. Yesterday she started to have lower abdominal pain, which worried her so her mother called the office to make an appointment for today but only her grandfather could bring her. She states that the pain is worse when she has the urge to go the bathroom and cannot produce any urine. The pain decreases a little between the urgency episodes. The patient rates the pain as a 6/10 today. She says that it has gotten worse every day over the past three days. She tried Tylenol with some relief.  She also reports fever chills, today developed nausea with one episode of vomiting.  The patient believes that she has a urinary tract infection because she remembers having one a few years ago that presented with the same symptoms.

 

Allergies:Penicillin(rash)

 

Current Mediation:MVI 1 tab PO daily.

 

Childhood Illnesses.

Chicken Pox. Asthma. Urinary Tract Infection age 15. Immunizations: Patient does not receive regular flu vaccines. Screening tests: Patient does not go to the eye doctors and states that she does not have any trouble with her vision.

Family History:

Mother -Lung cancer, heart disease, hypertension, diabetes. Father -Diabetes. Maternal grandfather deceased at 61 due to heart attack and maternal grandmother has diabetes and HTN. Paternal grandfather has a PMH seizures and paternal grandmother deceased at age 51 due to breast cancer

 

Social History:

Patient denies drug, ETOH or illicit drug use. She is a high school senior who plans to go into the military after graduation.

She is unemployed. She is not sexually active.

Exercise & Diet: Patient does have a regular exercise routine. Patient states that she cooks a lot of prepared frozen food for her or she just eats out.

 

Safety Measures: Wears seat belt.

HEENT: Denies headaches, sinus problems, epistaxis, hoarseness, dental problems, oral lesions, hearing loss or changes, nasal congestion. Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. Patient states she does not wear glasses or contacts. Patient has never seen an eye doctor

Neck: No neck pain or stiffness. She denies any limitation of motion or any lumps. She states she has noticed some swelling to her glands.

CV: Patient states she exercises 2 to 3 times a week. She denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema.

Lungs: Patient denies cough, SOB on exertion, difficulty breathing, wheezing, pain on inspiration, history of respiratory infections, exposure to TB, hemoptysis. Patient states she has not had a chest x-rays in the past. Her last TB skin test was done in September 2019 for volunteer work and it was negative.

GI: Denies, nausea, vomiting, dysphagia, reflux, pyrosis, loss of appetite, bloating, diarrhea, constipation, hematemesis, epigastric pain, hematochezia, food intolerance, flatulence, hemorrhoids or change in bowel habits.

GU: She denies heavy bleeding or incontinence. She had her first period at the age of 12. She is not currently sexually active. States she has dysuria with urinary urgency and frequency x 3 days.

PV: She denies deep leg pain, cold hands/feet, varicoseveins, thrombophlebitis, or leg cramps. Patient denies bruising or bleeds easily or history of any blood transfusions.

MSK: Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness, or changes in ROM.

Neuro: Patient denies transient weakness, numbness, muscular weakness, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, or paresthesia.

Endo: Patient denies thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained change in weight, changes in facial or body hair, changes in hat or glove size, or use of hormonal therapy.

Psych: Patient denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, and exposure to violence, or excessive anger.

Objective:

Physical Examination (PE):VS: BP: 102/60, HR: 76, RR: 18, Temp 98.5, weight: 129, height: 63inches, BMI: 22.7.

Gen: Patient well-nourished and appears stated age. No acute distress noted. Ambulating without assistance.

Skin:  No lesions present.

HEENT: Normocephalic. Eyes Sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular movements intact. Hearing is intact. Nose normal with no mucous, inflammation or lesions present. Nares patent. Septum is midline. Pink, moist mucous membranes. No missing or decayed teeth. Throat: no inflammation or lesions present.

Neck: Had a supple and with no pain, patient was negative for lymphadenopathy

CV: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: normal pulses bilaterally, no bruits present. Pedal Pulses: 2+ bilaterally. Extremities: no cyanosis, clubbing, or edema, less than 2 second refill noted

Lungs: Even and unlabored. Clear to auscultation bilaterally without wheezes, rales, or rhonchi. Abd: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active. No bruits.

GU: CVA and suprapubic tenderness on exam.

PV: Carotids -Regular, no bruits. Upper extremities warm, symmetrical in size, no lesions, no edema. Capillary refill < 2 sec bilaterally. Lower extremities warm, symmetrical in size, even hair distribution, no lesions, no edema, no varicosities, faint superficial vessels, toenails clear and pink. Pulses +2, regular, equal. No lymphadenopathy.

MSK: Normal ROM, joint stability normal in all extremities, no tenderness to palpation. No scoliosis noted.

Neuro: Grossly alert and oriented x3, communication ability within normal limits, attention and concentration normal.

Psych: Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Patient appears to be happy/content.

 

Sample Answer

 

Summary of history and examination

The patient is a 16-year-old female who presented to the clinic with complaints of burning sensation with urination. She reports having increased urgency and frequency for the past three days. It is accompanied by lower abdominal pain which she described as worse when she visits the bathroom and cannot produce any urine. She rates her pain at 6/10 but says it is getting worse. She tried Tylenol with some relief. She reports fever, chills, nausea, and an episode of vomiting. She has a history of the same symptoms 3 years ago where a urinary tract infection was diagnosed.

The patient has an allergy to penicillin (rash). She is currently on MVI 1tab PO daily. She has had a history of chickenpox, asthma, UTI. Her immunization status is not up to date and she has not been screened for eye problems. She has a family history of cancer, heart disease, seizures, hypertension, and diabetes.  She denies any drug, alcohol, or smoking exposure. She is not sexually active. She mostly eats cooked frozen food or fast foods. In the review of systems, nothing was contributory apart from the swollen glands in the neck. No history of heavy bleeding or incontinence. Her vital signs and anthropometric measurements were all within normal limits. She was well nourished, ambulating without assistance, and with no acute distress. There was suprapubic and costovertebral angle tenderness on genitourinary examination. No lymphadenopathy was noted and other systems were essentially non-contributory.

Differential diagnosis

According to Becknell et al., (2016), they include;

  • Cystitis
  • Pyelonephritis
  • Renal abscess
  • Nephrolithiasis

Plan of care

Diagnosis can be clinical as from the history of the patient and examination. The presence of genitourinary and systemic symptoms with costovertebral and suprapubic tenderness should point to both acute pyelonephritis and cystitis (Becknell et al., 2016). Investigation of this patient will include;

  1. Urinalysis- a midstream, clean-catch specimen is taken for dipstick analysis, microscopy, culture, and sensitivity. Dipstick analysis shows the presence of leukocyte esterase, white cell casts, and nitrites are most effective in diagnosing a urinary tract infection. Blood and protein have poor specificity and sensitivity for UTI. Microscopy may reveal pyuria >5WBC/high power field and presence of leukocytes >10/mcL, and bacteria. A sample may be obtained using a transurethral catheter. Gram staining will narrow down the type of bacteria that has colonized the urinary system. Culture and sensitivity will go a long way in treating the condition with specific antibiotics instead of broad-spectrum. coli accounts for approximately 80% of the cases. Others include; Pseudomonas, Klebsiella, Enterobacter, etc (Chon et al., 2016).
  2. Blood tests such as full hemogram, culture, and sensitivity may not be specific but will indicate the presence of an infection that is not localized. Elevated leukocyte count, erythrocyte sedimentation rate and CRP are expected (Chon et al., 2016).
  3. Other tests may include; imaging of the urinary tract by ultrasound to rule out obstruction by renal stones and hydronephrosis. Voiding cystourethrography detects anatomic abnormalities that may cause recurrent febrile UTIs. Imaging is rarely needed though (Hoberman et al., 2018).

Antibiotics are the mainstay for treating acute pyelonephritis or cystitis. The patient has an allergy to penicillin so other alternatives should be provided. Mild infections such as this one would warrant outpatient therapy. However, for a severe infection, and therefore, inpatient therapy with parenteral antibiotics would be appropriate (Becknell et al., 2016). Supportive treatment includes; adequate hydration, analgesia, and antipyretics (Acetaminophen 500 mg TDS PO for 3 days). Continuous monitoring for the effectiveness of therapy should be done (Chon et al., 2016).

Definitive treatment would include cephalosporins or fluoroquinolones.

  • Ceftriaxone 1g IM followed by oral trimethoprim-sulfamethoxazole 1 tablet PO BID for 14 days

Alternatives include; Ciprofloxacin 500mg BD PO for 7 days

  • Levofloxacin 750mg OD PO for 5days.
  • Cefaclor 500mg PO TID for 7days
  • Cefixime 400 mg/day PO BD/ OD for 7 days.

References

Becknell, B., Schober, M., Korbel, L., & Spencer, J. D. (2016). The diagnosis, evaluation, and treatment of acute and recurrent pediatric urinary tract infections. Expert review of anti-infective therapy, 13(1), 81-90.

Chon, C. H., Lai, F. C., & Shortliffe, L. M. D. (2016). Pediatric urinary tract infections. Pediatric Clinics, 48(6), 1441-1459.

Hoberman, A., Charron, M., Hickey, R. W., Baskin, M., Kearney, D. H., & Wald, E. R. (2018). Imaging studies after a first febrile urinary tract infection in young children. New England Journal of Medicine, 348(3), 195-202.

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