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Urinalysis - Case Study

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A medical team is standing at the bedside of a 95 year old woman admitted from a local nursing home to the AMU (acute medical unit). She has a background of mild cognitive impairment. She has experienced a general deterioration in her overall condition becoming bed-bound in recent days. She reports a pain near the sternal notch. Although she has a history of angina, she is able to tell the doctors that the current pain is different to past episodes of cardiac chest pain. She is reviewed by the cardiologists who feel that ACS is unlikely as a cause of her symptoms. She is consistently apyrexial post-admission and is hemodynamically stable. Her bloods show a normal urea and electrolytes and a normal white cell count. However, her CRP is elevated at 180 micromol/l (normal < 5). She has a history of UTIs in the past treated by her GP (family physician). In view of this history and the CRP level, the admitting doctor is concerned that the current deterioration is due to a UTI. The doctor reviewing the patient is presenting the case to the senior doctor on call. The following conversation takes place.

Junior doctor ‘If we can get a urine sample and it comes back positive, I’m going to start antibiotics for UTI’.

Senior doctor ‘What do you consider ‘positive’ in terms of treating her’?

Junior doctor laughs ‘Good question, well, I suppose if both the white cells and the nitrites are positive we should treat, particularly in view of the history of past UTI and the elevated CRP’.

Senior doctor ‘OK, so she’s grown something in the past then’.

Junior doctor ‘Yeah, she has some old MSUs on the system and there was at least one culture positive for E.Coli (>100,000 CFU)’.

Senior doctor ‘If she’s positive for both (white cells and nitrites) on the dipstick, what are you going to give her’?

Junior doctor ‘Well, she’s admitted from a nursing home so I’ll probably start her on IV piperacillin’ and give a shot of gent’.

Senior doctor ‘Heavy duty stuff’

Junior doctor ‘Yeah, but the consequences of not treating an infection over the weekend could be pretty bad’

Senior doctor ‘Yeah, but the consequences of C. diff could be worse. Remember the last one’

Junior doctor ’Oh yeah, that’s true’

The patient manages to produce a urine sample. Her urine is positive for white cells on microscopy (>100/mm3) and negative for nitrites on dipstick analysis.

Senior doctor ‘Could I suggest that we don’t treat her at this point and wait and see the urine culture results over the weekend, if the culture comes back positive or if she deteriorates we’ll treat (with antibiotics). Does anyone object to that?’

Well reader, do YOU object to that?

Q1. Should the patient be treated with antibiotics?

YesNo

Q2. Is the senior doctor's approach correct?

YesNo

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