I-Human Patient Sally Smith (G.U.) Essay

I-Human Patient Sally Smith (G.U.) Essay

I-Human Patient Sally Smith (G.U.) Essay

Case Study

Patient Case Study: Sally Smith
The patient in the case study, 34-year-old Sally Smith, has a positive blood culture and sensitivity results for Escherichia coli infection. She has been having a fever for the last two days, dysuria, urinary frequency, flank pain, and lightheadedness. She is also dehydrated and has suprapubic tenderness and a positive right flank punch test. The purpose of this paper is to appropriate additional objective data, and differential diagnoses, and develop a treatment for the patient.

ORDER A CUSTOM PAPER NOW

Additional Physical Examination and Diagnostic Tests
This patient is a female patient of reproductive age. Therefore, ruling out abdominal distention or suprapubic masses is essential in assessing the presence of pregnancy. Inspection of the external genitalia for foul smell or genital discharge is justifiable because of the close anatomical proximity between the genital and urinary systems (Ball et al., 2022). The presence of sexually transmitted infections cannot be ruled out in this patient. Moreover, she has had multiple sexual partners with the latest one within the last three months, and also a history of unprotected intercourse with the new partner. Additional tests would be necessary for this patient. A urine dipstick would be the best initial test to work up this patient’s urinary and abdominal complaints. The presence of nitrites and leucocytes will be used to diagnose urinary tract infections. The presence of glucose and ketones in her urine would suggest diabetic ketoacidosis.
Additional random blood glucose will be used to confirm current high sugars. Hemoglobin A1c is appropriate in this patient to establish the quality of glycemic control in this patient in the recent 2 to 3 months. A pregnancy test is a screening test whose outcomes will greatly influence this patient’s diagnosis and management. Complete blood count (CBC) and C-reactive protein (CRP) levels will be used to evaluate the presence of infection and systemic inflammation. Blood urea, electrolytes, and creatinine levels will be key assessments to rule out acute kidney injury and basic biochemical derangement that may impact the treatment. Kidney-Ureter-Bladder (KUB) ultrasound scan is important to rule out anatomical abnormalities that would lead to her symptoms. However, abdominal and pelvic CT scans would offer more sensitive and specific results.
Differential Diagnoses for this Patient
Based on the provided subjective and objective information about this patient, various diagnoses are possible. (N10) Acute pyelonephritis and (A41.51) E. coli septicemia are the most appropriate and top differential for this patient based on the patient’s symptoms, examination findings, and culture results. The positive right flank punch test highly supports the right acute pyelonephritis diagnosis. N30.90 Cystitis, unspecified without hematuria, is possible in this patient because of the lower urinary tract symptoms and the presence of suprapubic pain. N13.2 right hydronephrosis with renal calculus obstruction is another possible diagnosis in this patient, as suggested by a positive right flank punch test. Hydronephrosis is a complication that develops from ureteric or renal obstruction. One of the most common causes of this obstruction is renal calculi or kidney stones.
N15.1 Renal and a perinephric abscess is another differential that is supported by the positive costovertebral angle tenderness as well as the patient’s systemic and urinary symptoms (Hasel et al., 2022). E10.1 Insulin-dependent diabetes mellitus with ketoacidosis is also possible in this patient because she has type one diabetes and now presents with abdominal pain. Her recent blood sugars have also been persistently high, placing her at risk of diabetic ketoacidosis (DKA). A64 Unspecified sexually transmitted disease is also likely in this patient based on her recent sexual risks and presence of suprapubic pain. However, little information is given that would suffice this diagnosis, such as vaginal discharge and genital itchiness.
Assessment
The provided patient’s diagnosis is (N10 A41.51) acute pyelonephritis with E. coli bacteremia/ sepsis syndrome. Two ICD 10 codes describe this comprehensive diagnosis because these diagnoses are billable differently using the codes. Various guidelines can support the diagnosis of this diagnosis in this patient. This diagnosis is part of a complicated urinary tract infection. The complication is due to sepsis and the presence of diabetes mellitus as a risk factor. Infections Disease Society of America (IDSA) 2019 guidelines on clinical practice guidelines for the management of bacteriuria (Nicolle et al., 2019). The Michigan Hospital Medicine Safety Consortium also updated guidelines for the treatment of urinary tract infections in 2021. The National Institute for Health and Care Excellence (NICE) also provided UTI guidelines for all age cohorts and focused on antimicrobial prescribing (National Institute for Health and Care Excellence, 2018). Therefore, the assessment of this patient’s diagnosis can be supported by more than one guideline.
Treatment Plan for The Patient
The treatment of this patient includes both pharmacological and non-pharmacological strategies (Mylotte, 2021). Medication treatment includes a per oral 7-day course of trimethoprim because she has a complicated urinary tract infection (Rutten et al., 2020). Behaviorally, the patient would increase her daily water intake, ensure pre- or postcoital washing, and avoid spermicides and diaphragms (Rogers, 2022). This patient education is a health promotion strategy that would improve her Genitourinary health and reduce the risk of UTI recurring. Screening and treatment of her sexual partner would also be emphasized in this health promotion.
Conclusion
The patient is diabetic and presents with lower and upper urinary tract symptoms that suggest a complicated UTI, especially acute pyelonephritis. She is also systemically septic, as evidenced by positive culture for E. coli. Her other possible diagnoses include renal calculi, cystitis, perinephric abscess, diabetic ketoacidosis, and sexually transmitted infection. Her treatment will involve per oral trimethoprim and behavioral change strategies.

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2022). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier – Health Sciences Division.
Hasel, K., Salim, A., Adjei, P., & Gradon, J. D. (2022). An unusual case of perirenal abscess caused by Campylobacter and Peptostreptococcus species. Case Reports in Infectious Diseases, 2022, 4028085. https://doi.org/10.1155/2022/4028085
Mylotte, J. M. (2021). Decision tools and studies to improve the diagnosis of urinary tract infection in nursing home residents: A narrative review. Drugs & Aging, 38(1), 29–41. https://doi.org/10.1007/s40266-020-00814-6
National Institute for Health and Care Excellence. (2018). Overview | Urinary tract infection (lower): antimicrobial prescribing | Guidance | NICE. https://www.nice.org.uk/guidance/ng109
Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Köves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, 68(10), e83–e110. https://doi.org/10.1093/cid/ciy1121
Rogers, J. (2022). McCance & Huether’s pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.
Rutten, J. J. S., van Buul, L. W., Smalbrugge, M., Geerlings, S. E., Gerritsen, D. L., Natsch, S., Sloane, P. D., Veenhuizen, R. B., van der Wouden, J. C., & Hertogh, C. M. P. M. (2020). Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial. BMC Geriatrics, 20(1), 341. https://doi.org/10.1186/s12877-020-01662-0

ORDER A CUSTOM PAPER NOW

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.

Identify three to five possible conditions that may be considered in a differential diagnosis for the patient and their ICD 10 codes.

Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with GI or GU conditions.

Cc: painful urination

Case Problem Statement

Ms. S.S. is a 34-year-old female client who came to the clinic complaining of dysuria, frequency, urgency, dark-colored urine, right flank pain, and feeling feverish for the past two days with lightheadedness and high blood sugar readings. Physical exam finds temp 101.6F, HR of 110, chills, orthostatic blood pressure, suprapubic tenderness, and a positive right flank “punch” test. Her skin is decreased in turgor, with the tenting present and the absence of axillary moisture. PMH is significant for DM type 1 and renal calculi. She has had a new (male) sexual partner over the past three months with intermittent lack of condom use.

Tests

BC and sensitivity -BC x2 positive for E coli

Interpretation

Evidence of hematogenous spread of bacterial urinary tract infection.

Dx Feedback

Acute pyelonephritis with E.coli bacteremia/sepsis syndrome. No evidence of renal stones as contributing factor.

Alternative Dx

cystitis, nephrolithiasis/kidney calculi, perinephric abscess