URINARY TRACT INFECTION CASE STUDY Lorna Graham

URINARY TRACT INFECTION CASE STUDY Lorna Graham a 72 year old female is an inpatient in a general hospital. Lorna has been admitted to a medical ward for treatment of acute gastroenteritis. She presents with a history of diarrhoea and vomiting over the last 2 days. Lorna states she had a ‘seafood meal the other day and afterwards I became sick’. On admission to hospital her vital signs are Temperature 38.6 degrees Celsius Pulse 105/min Respiration 21/min Oxygen saturation 98% on room air. Blood Pressure 101/60 Other signs and symptoms on admission include feeling weak and lightheaded, decreased urine output, sweating, dry mouth, dry skin and poor skin turgor. Lorna also states that it is very painful when she urinates and that it ‘really burns when I pee’ Past medical and surgical history includes: Mild hypertension average 140/90 mmHg, hysterectomy 20 years ago, mild osteoarthritis, angina and ischaemic heart disease. Medications include: Imdur 20mg daily, anginine half tablet prn, aspirin half tablet daily. Allergies: nil Weight: 70kg Height: 170cm Lorna is assessed by the Doctor and investigations ordered. She is dehydrated and the Doctor inserts an intravenous (IV) bung into Lorna’s left forearm. The Dr orders insertion of an indwelling catheter (IDC) by the staff, as Lorna has a history of occasional urinary retention post hysterectomy and currently appears to be dehydrated. Lorna is placed on a fluid balance chart and all input and output is measured, including 1 hourly urine output measurement. Investigations ordered include blood tests of urea and electrolytes and full blood count, abdominal x-ray, ward level urinalysis, catheter specimen urine (CSU) for MC&S and blood cultures. Cardiovascular system (CVS): heart rate 105/min regular strong pulse, BP 101/60, nil raised jugular venous pressure, heart sounds normal, peripheries warm and well perfused, pink skin, skin dry, dry mucous membrane and skin turgor poor, urine output reduced. Respiratory system: Respiratory rate 21/min and regular, air entry clear in all lung fields, nil cough, oxygen saturations 98%, nil orthopnoea or dyspnoea. Gastrointestinal system: Abdomen slightly distended, but soft, Lorna complains of intermittent ‘crampy pain’, on palpation nil enlarged organs, nausea and vomiting every 2-3 hours on admission and relieved with maxalon as ordered, frequent loose offensive brown diarrhoea every 3-4 hrs. Abdominal x-ray: unremarkable. Central nervous system (CNS): intact and unremarkable. Renal: Urinalysis SG 1030, pH 6.0, nitrites +, leucocytes + and other NAD, urine offensive smelly, cloudy, and concentrated yellow colour, urine output via IDC low 25 mls/hr, skin turgor poor, urea 7 mmol/L, creatinine 0.09 mmol/L Results: Urea and electrolytes; Sodium (Na) 144 mmol/L, potassium (K) 3.7 mmol/L, BSL 4.0 mmol/L, urea 7 mmol/L, creatinine 0.09 mmol/L Full blood count; Haemoglobin (Hb) 130 g/L, platelets 200 × 109/L, White cell count (WCC) 7 × 109/L. On examination (OE) Lorna presents with dehydration secondary to probable acute gastroenteritis and ? caused by contaminated seafood. As gastroenteritis is suspected “contact precautions” are put in place to isolate Lorna from other patients. The Dr prescribes 2 bags of IV fluid, IV normal saline 1000ml bag with 20 mmol KCl at 100mls per hour for 8 hrs, then IV normal saline 1000mls at 80 mls/hr. Catheter specimen urine (CSU) results are: Microscopy: gram negative bacteria Culture: Escherichia coli (E-coli) Sensitivity: cefotaxime, Blood culture results are: Microscopy: nil Culture: nil Sensitivity: nil Lorna is nil by mouth, mouth care 2 hrly, fluid balance chart, measure 1 hrly IDC output and all bowel actions. 4 hrly temperature, 2 hrly pulse, resp rate, blood pressure & SaO2, Initially RIB with toilet privileges, TEDS, 2hrly leg exercises, Shower with supervision, IDC care BD. Medications ordered: Maxalon (metoclopramide) 10 mg IV 8 hrly prn, cefotaxime 1G IV 8 hrly (for UTI/cystitis) The next day Lorna’s vital signs are: Temperature 37.4 degrees Celsius Pulse 95/min Respiration 19/min Oxygen saturation 98% on room air Blood Pressure 120/65 Urine output 50mls per hour Lorna is not vomiting, however intermittent loose diarrhoea continues every 4-6 hours. Oral intake water only 50mls/hr and IV normal saline is prescribed at 50mls/hr. All input and output is measured on a fluid balance chart (FBC). Sit out of bed (SOOB) and encourage ambulation. Encourage increase oral intake and free fluids. Lorna is commenced on oral fluids and light diet. When IV antibiotics are completed she will be discharged to home and continue on a course of oral antibiotics to be taken for 5 days. Cephalexin 500 mg orally, 12-hourly for 5 days. Lorna is successfully discharged to home and has a full recovery back to normal health. Question How does the aeitology and pathophysiology of the Urinary Tract Infection case study relate to the clinical manifestation (sign and symptoms) of the patient in case study?

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