URINARY TRACT

INFECTIONS
GROUP D3
Patient: BB, a 55-year-old female. Wt: 58 kg, Ht: 158 cm

Chief Complaint: Increased urine frequency, urgency and lower back pain

History of Present Illness:

Claims that she was in her usual state of health until about 2 days ago, when she first
noticed an increased frequency and urgency to use the bathroom. She attributed her
symptoms to trying a different brand of coffee. She became more concerned when she
began experiencing a slight fever and lower back pain (5/10) yesterday evening.

Past Medical History:

 Hypertension x 10 yrs
 Type 2 DM x 8 yrs
 History of nephrolithiasis

Family History: Father died of MI at age 70

Social History: Occasional alcohol use on weekends; no history of smoking

Past Medication History:
 Atenolol 25 mg PO OD  Multivitamin 1 tab PO OD
 Metformin 500 mg PO BID  Calcium carbonate + vitamin D 500 mg PO BID
 Aspirin 325 mg PO OD

Allergies: NKDA

Physical Examination:
 GEN: Pleasant woman in mild discomfort
 VS : T 37.5 °C, BP 146/90, HR 70, RR 20, O2 Sat 98 % RA
 HEENT : PERRLA, EOMI
 CV : Regular rhythm rate (RRR), normal S1,S2, no M/R/G
 CHEST : Lungs Clear To Auscultation Bilaterally (CTAB)
 ABD: Soft NTND, (+) BS
 EXT : Warm, no C/C/E
 NEURO : A & O x 3
Laboratory Tests:

BUSE/Creat & Hematology:

 Na : 140 mmol/ L (Normal)  Hct : 0.35 (Low)
 K : 4.1 mmol/ L (Normal)  Hgb : 135 g/L (Normal)
 Cl : 100 mmol/ L (Normal)
 Lkc : 14.1 x 109/ L (High)
 HCO3 : 24 mmol/ L (Normal)
 Plt : 330 x 109/ L (Normal)
 BUN : 4.99 mmol/ L (Normal)
 HbA1c : 7.8 % (High)
 SCr : 88.4 μmol/ L (Normal)
 Glucose : 13.3 mmol/L (High)
Urinalysis:
 WBC 3+
 Gram (-) rods > 10⁵ CFU/ mL
 (+) Hematuria
 (+) Nitrite

Blood cultures: Pending