GRIFFINExpress

Urgent Care Clinics

Patient Record


Healthcare Provider: Alexandra Barbera


History and Physical Examination

Patient Name: Juan Mendoza

Date: November 6, 2017

Referral Source: Self

Data Source: Patient

Chief Complaint: Pain (burning sensation) during urination

Introduction and Presenting Concerns:
The patient is a 48-year-old diabetic male, Juan Mendoza. Juan works as a

supervisor for a 911 dispatch center and has been recently been working more due

to a shortage in operators. He states that he has increased coffee intake since the

increase in workload. He states that his PCP specializes in diabetic patients and that

he has adequate control of his diabetes. The patient regularly checks his blood

glucose levels and administers the correct amount of insulin.

Patient states that his symptoms started three days ago with an increase urge to

urinate and low urine volume. Patient suspected dehydration due to the coffee.

Shortly after symptoms began, patient began to experience painful urination

characteristic of the burning sensation. This morning, the patient reported a fever of

100.4F and body aches. Patient stated he had no history of similar symptoms.

Patient concerns are that of dehydration.

 Healthcare provider concerns include that of a UTI.

Clinical Findings:
Results of Urine Culture:
The patient, Juan, produced a urine sample with a dark auburn color. Several

tests were then preformed on the urine to come to a diagnosis of the patient.

A culture was performed to test for the presence of any bacteria in the urine.

Urinary tract infections are characteristic of bacteria colonizing units

between 103 to 105 colony forming units. The urine was first diluted using

serial dilution with 20 L of sample and 180 L of PBS solution. Samples with

a dilution factors of 10-1, 10-2, and 10-3 were plated, using 100 L, on nutrient

agar using the spread plate method. The plates were incubates at 37C and

later observed. The dilution factor 10-1 produced 101 colony forming units

on nutrient agar, dilution factor 10-2 exhibited no growth, and dilution factor

10-3 produced seven colony forming units. The lack of growth on the second

plate may have been the result of human error such as failure to plate the

solution. Since there were lack of growth in the second plate, the dilution

factor 10-1 was utilized to formulate an accurate number of how many

bacteria, CFU/mL, was in the patient sample.

()
=
()

101 C

= 1.01 10
10@A 0.1
 A result of 1.01 104 cfu/mL is supportive of a urinary tract infection, which

is characteristic of 103 to 105 cfu/mL of urine. More tests are needed to

determine what the bacteria is to correctly diagnose the patient.

Results of Microscopic Analysis:
A slide was prepared using Gram staining techniques to analyze the cells

causing the infection. The Gram-stain was performed by heat fixing the

smear, and using crystal violet, iodine, ethanol, water and safranin. Gram-

positive cells stain purple due to their thick peptidoglycan while Gram-

negative cells have a single layer of peptidoglycan allowing the crystal violet

to escape and safranin stain the cells pink. Human error occurred during

staining and observation of the patient cell sample which resulted in a light

purple bacillus. When done correctly, the slide should have presented with

Gram-negative, pink, bacilli arranged in singles. This shows the importance

of making multiple slides to ensure correct results.

Results of Urinalysis:
A urine chemistry dipstick assay was performed using dipstick lot number

URS7050087 with an expiration date of 2019-07. While they might not be

100% accurate, urine dipsticks are frequently used in diagnosis of a urinary

tract infection (1). The test resulted in normal findings of the levels of

glucose, bilirubin, ketones, urobilinogenn, nitrites and leukocytes. The pH

was normal, presenting at 6. The specific gravity was normal presenting at

1.020 g/mL. Abnormal findings were that of blood and protein. The blood
 test determined that there was an elevated amount of blood in the urine, +++

ery/L. The protein test was also elevated and presented at 100++ mg/dL.

The normal specific gravity levels can conclude that the urine was not

abnormally concentrated and therefore, the patient was not dehydrated.

The blood in the urine are a common characteristic of urinary tract infection

(2). UTIs are also commonly associated with a proteinuria positive strip test;

however, it is not a definitive method in patients with microalbuminuria or

patients with diabetes (2). Diet, stress, and vigorous exercise may also

increase protein levels in the urine (1).

Test Test Expected Results Normal / Abnormal
performed Range
(Y/N)

Glucose Y Negative Negative Normal l Abnormal

Bilirubin Y Negative Negative
Normal l Abnormal


Ketone Y Negative Negative Normal l Abnormal

Specific Y 1.015-1.025 1.020 g/mL
Normal l Abnormal
Gravity g/mL

Blood Y Negative +++ ery/L Normal Abnormal

pH Y 4.5-8 6 l
Normal l Abnormal

Protein Y <15.0 mg/dL Elevated, 100++
Normal Abnormal
mg/dL l
Urobilinogenn Y 0.2(3.5) mg/dL Negative Normal l Abnormal

Nitrite Y Negative Negative Normal l Abnormal

Leukocytes Y Negative Negative
Normal l Abnormal

Diagnostic Focus and Assessment:
The signs, symptoms and the test preformed in the laboratory led to the diagnosis of

a urinary tract infection in the patient, Juan Mendoza. The bacteria that was observed was a

Gram-negative bacillus. Escherichia coli is a Gram-negative bacillus and is the most

common cause of a UTI (3). Additional tests performed on the suspected bacteria can help

to confirm the suspected cause. The urinary tract infection process occurs when the

bacteria enter the urethra and multiplies in the bladder. E. coli is a motile bacterium in

which the flagella adds to the pathogens virulence factors and can be used to explain how

the bacteria travels to the bladder to multiply, but it is not important for the maintenance

of infection (4).

Symptoms of a UTI typically include a strong urge to urinate, burning sensation

while urinating, passing frequent, but small amounts of urine, cloudy urine, red urine (a

sign of blood in the urine), strong-smelling urine, and a low-grade fever in men (8). The

patient presented with a strong urge to urinate, burning sensation while urinating,

frequent urination, low-grade fever and a low amount or urine. The urine was also an

auburn color and contained blood, all of which correlate to the symptoms of a urinary tract

infection. The incubation time of a urinary tract infection is variable depending on the

pathogen; however, with E. coli as the pathogen, the time is usually three to eight days (6).

When urination begins to become painful, medical help should be sought within twenty-

four hours to prevent the progression into an upper urinary tract infection (6).

In men, UTIs are more common in older men with prostatic diseases or obstructions

and in younger men participating in anal sex, an uncircumcised penis, or a partner who

harbors the pathogen (5). Anal sex offers the exposure of the urethra to rectum bacteria

such as E. coli, as well as sex with a partner whose is colonized with the bacteria (5). Men

who did not undergo a circumcision may increase the colonization of the glans and prepuce

resulting in an increased chance of infection (5). A urinary tract infection may be

considered complicated if a patient has a predisposed condition to persistent infection

(5). A predisposed condition that would make a patient more susceptible to a UTI would be

because of a suppressed immune system. Diabetes is a disease that suppresses the immune

system and is present in the patient, Juan (3). The immune system is suppressed in

diabetes due to reduced neutrophil functions and defective C3 mediated optimization (9).

Complications are rare in lower UTIs, but if left untreated or treated incorrectly,

complications can arise (3). Complications include that of recurrent infections, permanent

kidney damage from pyelonephritis, urethral narrowing in men, and life-threatening sepsis

especially in upper urinary tract infections (3).

The duration of illness is dependent on when antibiotics are taken. Once antibiotic

treatment for the UTI begins, symptoms usually subside within a few days but the

antibiotic course may exceed past the disappearance of symptoms (7). The patient is

expected to make a full recovery as long as he follows the treatment protocol. If Juan fails to

follow the treatment protocol, the infection could worsen, or become reoccurring. If Juan

contracted the UTI by a suspected sexual transmission from anal sex, the partner would not

need to be notified as the bacteria is part of the normal intestinal flora (6). UTIs are

typically not contagious to other people (6) so people he came into contact with would not

need to be informed of his infection.

Therapeutic Focus and Assessment:
The patient would be tested for antibiotic resistance to determine which antibiotic

course would be utilized. If the prevalence of drug resistance is under 20 percent, the

patient would be treated with trimethoprim-sulfamethoxazole (10). The treatment

regimen he would follow would include taking the TMP-SMX in a double strength tablet of

160/800 mg, twice a day, daily for 7 to 14 days (10). The 7-day treatment is likely to be
sufficient (10). Oral fluoroquinolones, such as ciprofloxacin, would be an option for an

alternative course of antibiotics (10). Ciprofloxacin would be prescribed in 500 mg tablets,

twice a day for 10 days (10). The 10-day duration would be implemented due to the

patients compromised immune system due to patients diabetes. Patient is required to

maintain control over his diabetes by correct insulin dosing. Patient is required to return to

the doctors office or have a phone interview with the office after 48 to 72 hours for a

follow up to ensure the antibiotic prescribed is working effectively (10). If symptoms are

not going away, resistance may be present or an underlying prostatitis (10). Treatment of

resistance or prostatitis would be determined at the time of next visit, if necessary.

Patient would also be prescribed a phenazopyridine, such as Pyridium, or

recommended to take the over the counter version, Uristat, to alleviate pain symptoms

associated with painful urination (11). This medication is not to be taken for more than 48

hours and not to be taken in place of an antibiotic (11). The medications change the color of

the urine and has the potential to stain contacts and clothing (11). If Juan wore contacts, he

would be advised to wear his glasses during the treatment with Pyridium.

At home remedies are not to be used to treat the urinary tract infection but can be

implemented to decrease the incidence of a UTI. Prevention tactics include drinking plenty

of water to keep the body hydrated, drinking cranberry juice, and emptying the bladder

after sexual intercourse (3). Juan is advised to follow these prevention methods to reduce

the risk of reoccurring UTIs. Juan is to return to work but advised to lower stress levels to

ensure his immune system is working correctly. Juan can do this by getting enough sleep at

night or finding alternative ways to distress such as exercise or meditation.

Works Cited

1. Schmiemann G, Kniehl E, Gebhardt K, Matejczyk M, Hummers-Pradier E. The

Diagnosis of Urinary Tract Infection. Duetsches Arteblatt International. 2010

[accessed 2017 Nov 4];107(21):361367.

2. Carter JL, Tomson CRV, Stevens PE, Lamb EJ. Does urinary tract infection cause

proteinuria or microalbuminuria? A systematic review. Nephrology Dialysis

Transplantation. 2006;21(11):30313037

https://academic.oup.com/ndt/article/21/11/3031/1873310

3. Urinary tract infection (UTI). Mayo Clinic. 2017 Aug 25 [accessed 2017 Nov 5].

https://www.mayoclinic.org/diseases-conditions/urinary-tract-

infection/symptoms-causes/syc-20353447

4. Lane MC, Lockatell V, Monterosso G, Lamphier D, Weinert J, Hebel JR, Johnson DE,

Mobley HLT. Role of Motility in the Colonization of Uropathogenic Escherichia coli in

the Urinary Tract. Infection and Immunity. 2005;73(11):76447656.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1273871/

5. Orensteain R, Wong E. Urinary Tract Infections in Adults. American Family

Physician. 1999;59(5):12251234.

http://www.aafp.org/afp/1999/0301/p1225.html

6. Davis CP. Is a Urinary Tract Infection (UTI) Contagious? Sheil W, editor.

MedicineNet. [accessed 2017 Nov 5].

https://www.medicinenet.com/is_a_urinary_tract_infection_uti_contagious/article.h

tm
7. Urinary tract infection (UTI). Mayo Clinic. 2017 Aug 25 [accessed 2017 Nov 6].

https://www.mayoclinic.org/diseases-conditions/urinary-tract-

infection/diagnosis-treatment/drc-20353453

8. Castle EP. Bladder infection in men. Mayo Clinic. 2015 May 14 [accessed 2017 Nov

6]. https://www.mayoclinic.org/diseases-conditions/cystitis/expert-

answers/bladder-infection/faq-20058552

9. Aliabadi Z, Foster J, Slonczewski. Microbiology The Human Experience. New York

(NY): W.W. Norton & Company; 2016.

10. Hooton T. Acute uncomplicated cystitis and pyelonephritis in men Caulderwood S,

editor. UpToDate. 2016 Jan 5 [accessed 2017 Nov 6].

https://www.uptodate.com/contents/acute-uncomplicated-cystitis-and-

pyelonephritis-in-men?source=search_result&search=Urinary Tract

Infection&selectedTitle=9~150

11. Hooton T. Patient education: Urinary tract infections in adolescents and adults

(Beyond the Basics) Caulderwood S, editor. UpToDate. 2017 Oct 25 [accessed 2017

Nov 6]. https://www.uptodate.com/contents/urinary-tract-infections-in-

adolescents-and-adults-beyond-the-basics#H7