Case Study: A Urinary Tract Infection
Chief Complaint: "I can't stop peeing. I know where every bathroom is on every highway and street in the entire state. I spent half of my time worrying about having an accident and wetting myself."
History of Present Illness: This 26-year-old African-American female, Lily R., reports that for the last four weeks, she has been constantly going to the bathroom to urinate, and experiences a burning sensation whenever she eliminates. She states that she literally has to go to the bathroom every hour or two; in addition, she states that her urine has a very strong odor which is different than anything she has ever noticed. She wonders aloud if the infection may have been caused by the fact that she has switched methods of birth control so that she has been using a diaphragm for about five or six weeks. This occurred because she had begun having a sporadic sexual relationship with a man who refuses to use condoms, and expects her to use the birth control method for the couple. She has tried drinking cranberry juice, which was suggested to her by a family member, in order to get rid of the problem, but has only found that as time goes on, it seems to get worse.
The patient reports that she has only had a urinary tract infection once before, about four years ago, and it followed a bout with severe diarrhea; her doctor suggested that bacteria from her rectal area had entered the vagina, leading to the infection. At that time, she was treated with a 10 day course of antibiotics, and the infection seemed to clear up almost immediately.
Allergies: Ms.R reports that she is allergic to eggs, tetracycline, sulfa drugs, and the allergy drug Augmentin, each of which have caused her to develop a rash around her mouth and face, as well as a low grade fever. She also has several sensitivities to skin products, such as perfumes, deodorant soaps, and other items that contain scents; when she is exposed to such products, including detergents that are not hypoallergenic, she develops a rash on the area of contact, which can range from a small spot on her face to an angry red rash that covers her entire body. In addition, she has seasonal allergies because she is allergic to grass, pollen, and mold. She is most affected by the seasonal allergies during the spring and fall, especially when the season has been a rainy one. Seasonal allergies affect her by causing her to have a severe sinus headache, itchy eyes, and a runny nose. In addition, she becomes extremely tired from those symptoms.
Medications: The patient is on several oral medications: Avapro, 300 mg HS; Zocor, 10 Mg HS; Diazepam, 2 mg taken at bedtime; Klonopin, 1 mg, taken at bedtime; and takes oral vitamins on a daily basis: Vitamin D, 1000 Mg, Vitamin C, 500 Mg, Omega-3 Fish Oil, 1000 Mg, Glucosamine Chondroitin, 1200 Mg BID, and Vitamin E, 400 IU per day. She periodically takes Robitussin, the over-the-counter cough medicine. She takes Allegra, 60 mg, once or twice a day during allergy season. In addition, she sometimes uses Benadryl, the over-the-counter medication that relieve her allergy symptoms and also helps her to sleep.
Past Medical and Surgical History: The patient was diagnosed with hypertension and high cholesterol at age 20, and has been taking medication for those conditions ever since. In addition, she experiences chronic knee and back pain, the result of an injury she sustained during a car accident five years ago. She has been smoking since the age of 15, and reports that she has a chronic cough for which she sometimes takes over-the-counter cough medicine. She has always had difficulty sleeping, she reports; as a child, she frequently stayed up almost all night because of her inability to sleep. For many years, a physician has been prescribing medication for her to take at bedtime, which has helped her sleep approximately six or seven hours per night.
The patient also has a history of uterine fibroid tumors, which cause her to have very heavy periods. She has been told that if the bleeding continues or gets worse, she may need to have surgery to remove the fibroids and eventually, may be a candidate for a hysterectomy. She states that she hopes that she can delay that until after she has a child or two, but given her family history, which will appear below, that may not be possible.
The back pain that she has experienced for the last years makes her a candidate for back surgery at some point, if the pain becomes intolerable and if she is open to that idea. Up until now, she has heard so many negative stories about back surgeries that she has not been willing to consider that as an option. Instead, she has tried using alternative medication such as the glucosamine and omega-3 fish oil to try to relieve the pain.
Family History: Ms.R. is the oldest of three children born to her parents, both of whom are still alive. Her parents have been smokers for over three decades; her father, age 55, has been diagnosed with emphysema, and her mother, age 56, has had breast cancer resulting in lumpectomies: one more than 10 years ago, when she was in her 40s, and the second one, last year. Both of her parents have high blood pressure and high cholesterol, for which they are receiving treatment in the form of medication, dietary changes, and exercise programs. Lily's mother also had fibroid tumors throughout her childbearing years, resulting in a hysterectomy at age 40. The patient recalls that her mother was extremely depressed following that procedure, taking little interest or pleasure in anything but refusing to seek professional help for her illness. Eventually, however, she was persuaded to attend a breast cancer support group, and through that activity, she formed a network of peers with whom she keeps in touch and socializes. The patient states that any form of treatment for mental health is looked upon with extreme skepticism and negativity within her family, although they agree that her mother's support group has been very helpful. Her father had prostate cancer eight years ago and was treated with radiation; since then, he has gone for checkups every six months, and has remained in remission so far.
The patient's two younger siblings, a brother who is age 24, and a sister who is age 20, also have hypertension and high cholesterol, and are both smokers as well. Her brother was diagnosed with bipolar illness two years ago, after many years of his erratic, unpredictable behavior which was largely rationalized and ignored by family members. It was only after he and some friends broke into a store and stole some liquor that he became involved with the court system, which ordered a psychiatric evaluation. That process led to his diagnosis, and he has subsequently been tried on a variety of medications, including lithium, in an effort to help stabilize his mood. Due to the family's attitude about mental illness and its treatment, however, her brother has been noncompliant with any medication regimens and his family has enabled that behavior. Her brother works as a grocery store stock person, the patient expressing that he has been limited in his potential to accomplish much of anything professionally because of his bipolar illness.
The patient's 20-year-old sister is married to her high school boyfriend and has one child, age 4. She has been living with her boyfriend since she became pregnant at age 16; nevertheless, she was able to complete high school with her mother providing childcare and is currently attending college. She hopes to become a physician's assistant. Like her older sister, this young woman has a history of fibroid tumors and has had to have one surgical procedure to remove fibroids due to excessive bleeding. She has no history of mental illness, depression, or any emotional condition that would necessitate treatment up until now.
Social History: The patient lives alone in a condominium that she rents close to her job as a childcare worker in a day care center. As stated, since the age of 15 she has smoked cigarettes on a regular basis, smoking one pack a day, and is not currently motivated to quit smoking, despite the fact that she is well aware of the negative health consequences of continuing. She reports that during her late teenage years, she drank rather heavily, with friends on weekends, at parties and other social events, occasionally to the point of having blackouts. She stopped drinking entirely after her car accident, because the driver of the other car involved was drunk and she felt that she could have easily caused an accident that had even more serious consequences or might have killed herself or someone else. She reports that she occasionally smoked pot as a teenager, as keeps marijuana in her house in order to relax and, at times, "get a good night's sleep."
Review of Systems: The patient acknowledges that she is extremely tired most of the time, due to the fact that she has difficulty falling asleep and reports early-morning awakening as well. She denies experiencing fever, chills, or weight loss or gain; there has been no change in her appetite or general activity level. She is slightly overweight, and refused to be weighed as she says she does not want to add another thing to her list of worries and inadequacies. She denies dizziness, weakness, numbness, or alterations in her sleep, mood, or memory: her sleep issues have been long-standing for years. She denies having chest pain, heart palpitations or edema, but admits to having shortness of breath when she climbs stairs or walk quickly for more than five or ten minutes. Regarding her respiratory condition, she acknowledges a chronic cough but denies wheezing or having trouble breathing. She has never been diagnosed with asthma. Regarding her gastrointestinal status, she does not experience constipation but admits to having slight abdominal pain recently, occasional diarrhea but reports no changes in her stool patterns.
Physical Exam: On exam, the patient's blood pressure was 130/90, heart rate was 88, respiration was 17, and the patient's temperature was 98.2. She appeared to be mentally alert, demonstrating a sense of humor and wit, had some patches of dry skin on her face, and demonstrated a full range of motion regarding her ability to walk, stand, and bend, although the latter was somewhat difficult because of back pain. Examination of her abdomen indicated a normal size liver as well is the presence of abdominal fluid within normal limits, no unusual bowel sounds and slight tenderness in response to palpitations. Her nerves, muscles strength, reflexes, balance, and emotional state appeared to be within normal limits, and her respiration was within normal limits although when asked to take a deep breath, the patient coughed several times (refer above to smoking history.) A pelvic exam revealed sensitivity when touched examined as well as a strong, abnormal odor.
Lab Testing: No test results available as this was patient's first appointment to address problem.
Assessment:
- Rule/out urinary tract infection
- No other acute problems noted
- Chronic Diagnoses: Hypertension, high cholesterol, smoker's cough, back pain, fibroid tumors
- Preventive Care: See below.
Plan: Refer to lab to provide clean urine sample for urinalysis and send out for culturing
Recommend use of analgesics to address pain while urinating while awaiting results of lab tests and prescription of antibiotics to address infection
Recommend weekly blood pressure checks either at home or at local clinics; follow-ups with clinic on regular basis to check cholesterol and provide counseling about diet and exercise.
Patient Education about smoking cessation programs
Referral to Family-Planning Services regarding birth control methods, relationship issues
Referral to Gynecological Services given her own as well as family history of fibroid tumors
Referral to Orthopedist for evaluation of back pain
Narrative: "The patient is a 26-year-old African-American female who presents with complaints of frequent and urgent, as well as painful, urination, resulting in anxiety secondary to worrying about incontinence. The symptoms started about four weeks ago, shortly after the patient began using a diaphragm as a means of birth control. Patient has been using tobacco for over 10 years, has a family history that includes many smokers, has minimal alcohol and drug use. On exam, patient experienced tenderness during abdominal palpitations, and had a strong vaginal odor that she reports has occurred during her recent urinary symptoms. The patient has a history of hypertension and high cholesterol, with a family history loaded in these areas as well. There is also a strong family history of females with fibroid tumors, which the patient herself has as well. The patient also has chronic back pain following a car accident several years ago. On exam, blood pressure was slightly elevated, other vitals were within normal limits, with a chronic cough present that clearly emanates from her many years of tobacco use.
"Her symptoms are strongly suggestive of a urinary tract infection, and lab work was ordered to determine whether and which bacteria are present, in order to determine which antibiotic will most successfully treat her infection. In the meantime, the use of analgesics to control the pain of urination was recommended, over-the-counter remedies such as Tylenol or aspirin.
"In addition, the patient was given several referrals to address her chronic conditions, including hypertension, high cholesterol, chronic back pain, as well as preventive care regarding patient education about birth control methods, smoking cessation, and relationship skills. It was recommended that she follow up with regular blood pressure screenings either at home or in a clinic, cholesterol readings and patient education regarding dietary changes and lifestyle changes that would help control those chronic conditions."