case protocol uti

7/27/2019 Case Protocol Uti

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CASE:

This is a case of a 4 y/o male presenting with acute abdominal pain. Abdominal pain is acommon problem in children. Although most children with acute abdominal pain have self limited conditions, the pain may herald a surgical and medical emergency. Table 1 lists manycauses of acute abdominal pain in children. (Leung and Sigalet, 2003)

GASTROINTESTINALCAUSESGastroenteritisAppendicitisMesenteric LymphadenitisConstipation

Abdominal TraumaIntestinal ObstructionPeritonitisFood PoisoningPeptic Ulcer Meckels Diverticulum Inflammatory BowelDiseaseLactose Intolerance

GENITOURINARYCAUSESUrinary Tract InfectionUrinary calculiDysmenorrheaMittelschmerz

Pelvic InflammatoryDiseaseThreatened abortionEctopic PregnancyOvarian/Testicular torsionEndometriosisHematocolpos

DRUGS AND TOXINSErythromycinSalicylatesLead PoisoningVenoms

LIVER,SPLEEN AND

BILIARY TRACTDISORDERSHepatitisCholecystitisCholelithiasisSplenic InfarctionRupture of the SpleenPancreatitis

METABOLIC

DISORDERSDiabetic ketoacidosisHypoglycemiaPorphyriaAcute Adrenal Insufficiency

PULMONARY CAUSES

PneumoniaDiaphragmaticPleurisy

HEMATOLOGICDISORDERSSickle cell anemia

Henoch-Schonlein purpuraHemolyticUremicSyndrome

MISCELLANEOUSInfantile ColicFunctional Pain

PharyngitisAngioneurotic EdemaFamilialMediterranean Fever


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In evaluating children with abdominal pain, a thorough history is required to identify the mostlikely cause. An initial evaluation of the history is followed by a physical examination and a

reassessment of certain points in the history.Age is a key factor in the evaluation of abdominal pain. Table 2 shows the differential diagnosisof acute abdominal pain by predominant age

Birth to One year Two to Five Years Six to 11 years 12 to 18 yearsInfantile ColicGastroenteritisConstipationUrinary TractInfectionIntussusception

VolvolusIncarcerated herniaHirschsprungsDisease

GastroenteritisAppendicitisConstipationUrinary TractInfectionIntussusception

VolvolusTraumaPharyngitisSickle Cell CrisisHenoch-Schonlein

purpuraMesentericLymphadenitis

GastroenteritisAppendicitisConstipationFunctional PainUrinary TractInfection

TraumaPharyngitisPneumoniaSickle Cell CrisisHenoch Schonlein

purpuraMesentericLymphadenitis

AppendicitisGastroenteritisConstipationDysmenorrheaMittelschmerzPelvic Inflammatory

DiseaseThreatenedAbortionEctopic PregnancyOvarian/Testicular Torsion

The case is a 4 y/o male, hence, other causes of acute abdominal pain were ruled out such asinfantile colic, incarcerated hernia, hirschsprungs disease , functional pain, dysmenorrhea,mittelschmerz, , pelvic inflammatory disease, threatened abortion, ectopic pregnancy, ovarianand testicular torsion.Fever in the patient indicates an underlying infection or inflammation. However, review of systems revealed that there is no cough, no sore throat, no difficulty in swallowing. Therefore,

pneumonia and pharyngitis as cause of the abdominal pain in this patient is not a consideration.A history of trauma may indicate the cause of abdominal pain. But it is also not considered sincethere is no obvious history of trauma.Gastroenteritis is the most common cause of abdominal pain in children. However, diarrhea isoften associated with gastroenteritis or food poisoning and should also be common among

household contacts for which the patient does not have.Constipation is ruled out since abdominal pain is most often left-sided or suprapubic and the patient has no change in bowel movement pattern.A family history of sickle cell anemia may indicate the diagnosis. The patients ethnic

background is important because sickle cell anemia is most common in blacks of Africanorigin.The case is a 4 y/o Filipino male, hence, sickle cell anemia is eliminated.Joint pain, rash and hematuria suggest Henoch-Schonlein purpura which are all absent in the

patient.


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Intestinal obstruction produces a characteristic cramping abdominal pain. Causes of intestinalobstruction include volvulus, intussusception, incarcerated hernia, and postoperative adhesions.The patient in this case has no signs of intestinal obstruction such as abdominal distention,decreased bowel sounds and persistent vomiting. No history of any operation was alsomentioned.

Mesenteric lymphadenitis is often associated with adenoviral infection for which the patient inthis case does not have. The condition mimics appendicitis except the pain is more diffuse, nosigns of peritonitis and generalized lymphadenopathy may be present which cannot be seen inthe patient.Appendicitis is the most common surgical condition in children who present with abdominal

pain. It presents classically with fever, vomiting, point tenderness over McBurney point, andsigns of peritoneal irritation. Psoas sign, Obturator test, guarding, rebound tenderness were allnegative in this patient. Hence, appendicitis is ruled out.Here is a case of a 4 y/o male with abdominal pain, fever and vomiting. My initial impressionwas Systemic Viral Illness (SVI), t/c UTI since there is also frequency in urination. Initiallaboratory studies in the patient include a complete blood count and urinalysis. CBC showed

leukocytosis (WBC:12.6) which indicates an infection. Urinalysis showed 10-13 pus cells/hpf which clearly points to a urinary tract infection (UTI) in this case.

Laboratory Results:CBC: Hgb-110 Hct-0.35 WBC-12.6 Seg-74 Lym-20 Mono-4 Eos-2 Plt-483Urinalysis: pus cells-10 to 13/hpf rbc-4 to 6 Protein-trace Mucous Threads-moderateSugar-negative Occult blood-negative Bacteria-few

Knowing that the patient has UTI, urine culture and sensitivity was requested since it is still thegold standard in the diagnosis of the said disease. I also requested for an ultrasound of thekidneys and urinary bladder to check if there is any abnormality in the urinary tract . Thrapeuticsinclude Paracetamol at 10mkd, Cefuroxime at 20mkd and Oresol vol/vol replacement. I advisedthe patient to have small frequent feedings, to follow up after two days if still febrile and tofollow up anytime if symptoms persist. Otherwise, the patient can follow up after a week withurine cs and utz of kub results, as well as a repeat urinalysis result.Upon follow up after a wk, the patient symptoms resolved. Urine CS revealed a negative result,UTZ of KUB showed normal findings and repeat urinalysis after a week of treatment revealednormal result.

DIAGNOSIS: Urinary Tract Infection

OBJECTIVES:1. Know the definition of UTI in children and its prevalence2. Determine the etiology and pathogenesis of UTI3. Give the clinical presentation of UTI based on age and its diagnosis4. Current treatment recommendations for UTI and its prevention


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