discussion response

Respond to below casestudy

· Describe how culture might impact the diagnosis, management, and follow-up care of patients with the genitourinary disorders your colleagues discussed.

· Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives.

HPI: This is a 3 year old girl with a 2-day history of complaints of dysuria with frequent episodes of enuresis despite potty training about 7 months ago. She is afebrile and denies vomiting. PMH: Last UTI, 6 months ago. PE: Dipstick voided urine analysis reveals: specific gravity 1.015, Protein 1+ non-hemolyzed blood, 1+ nitrites, 1+ leukocytes, and glucose-negative.

 

· What additional questions will you ask?

· Does the child have neurogenic bladder, detrusor-sphincter dyssnergia, and other urinary tract anomalies that could increase her risk for developing a UTI?

· Is there a family history of recurrent UTI?

· Was she treated for her last UTI? Did she take the entire course of antibiotics? Did the symptoms go away?

· Is the child given enough time to completely empty the bladder?

· Is the child on new medications?

· Any new stressors?

· How late does she eat and drink?

· Does she go to daycare? Who watches her?

· Does she wear pull ups and how often are they changed

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· What is your most likely diagnosis and why?

· Due to the patient’s presenting symptoms despite being potty trained and urinalysis results, she the most likely diagnosis for this patient is acute cystitis.  The disorder is characterized by urinary urgency, frequency, dysuria, suprapubic discomfort and, in some patients, a low-grade fever. Gross hematuria may also be evident. Patients with cystitis typically do not have a high fever, chills, flank pain, or costovertebral angle tenderness. These latter findings are more indicative of upper tract infection (pyelonephritis

 

· What additional examinations or diagnostic tests, if any will you conduct?

· Obtain a midstream urine specimen for analysis and culture

. Because this is her second infection, urine should be sent to the laboratory for culture and sensitivity analysis because this patient may be more likely to harbor an organism that is resistant to commonly used antibiotics.

· Differentials

· Pyelonephritis- Patients with Pylonephritis or upper tract infection tend to be the above symptoms with high fever, chills, flank pain, or costovertebral angle tenderness.

· acute urethritis- typically patients are not febrile and do not have suprapubic discomfort. However, they may have a purulent urethral discharge, a finding which is not usually present in women with acute cystitis.

· Vaginitis- this diagnosis was ruled out due to positive urine dipstick, absence of vaginal discharge as well as vaginal irritation.

· Overactive bladder: ruled out due to positive dipstick.

· Constipation-

· How will you treat this child?

· In spite of treating this patient with antibiotics to eradicate the causative agent, a culture and sensitivity should be ordered to determine exact causative agent and what works best.  Management should also be geared towards symptomatic relief in order to prevent any further damage and discomfort.

· A choice from below would be appropriate.

. Amoxicillin 25-50mg/kg/day BID for 3-7 days or

. Amoxicillin-clavulanate 25-45mg/kg/day BID for 3-7 days

. Cephalexin 25-50mg/kg/day QID (max: 4g)

. Cefixime 16mg/kg/day BID X1day then 8mg/kg/day BID thereafter for 3-7 days

. TMP-SMX 8-10mg/kg/day BID for 3-7 days

. Tylenol and Motrin as needed for pain and discomfort

· Patient Education, Health Promotion & Anticipatory guidance:

· The parents should be instructed to increase fluid intake and encourage frequent voiding.

· Finish entire course of antibiotics

· Avoid any bouts of constipation because treatment of constipation can help to prevent subsequent UTIs

·  Avoid bubble baths, perfumed soaps, tight pants, and wear cotton under wears

· Decrease intake of caffeine, carbonated beverages, chocolate, and citrus

· Teach parents and child to wipe from front to back to prevent contamination of the urethra after bowel movements.

· If lower tract infections are not treated adequately, the obstetric patient may develop an ascending infection (pyelonephritis). Ascending infection results from stasis of urine flow within the ureters caused by the inhibitory effect of progesterone on smooth muscle peristalsis and the compressive effect of the uterus on the ureters, particularly the right ureter. Pyelonephritis, in turn, may be associated with bacteremia, septic shock and ARDS.

· Teach your child to use the toilet when she feels the urge and not to hold it. Urine that is held in the bladder can help bacteria grow. This is also important for bowel movements.

· Children with constipation are more prone to UTIs. If your child has hard stools or painful bowel movements, try to increase the fiber in her diet.

· cranberry juice (50 mL) daily to prevent symptomatic UTI recurrence

 

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· Education strategies and socio-cultural barriers that might impact the treatment and management plans.

· Education, income, marital status, and source of health insurance are all components of socioeconomic status  which may differ by race/ethnicity, and underlay a broader latent relationship between a person’s status in society and the connections to overall health, healthcare access, or individual attitudes and behaviors toward health and well-being of the individual and the family as a whole.  With this particular family, we are unsure of any of the information, so education is key.  A tech back and demonstration should be done with the family as well as the child.

·

· What immunizations should this child have had? What additional anticipatory guidance should be provided today?

· Lead testing should occur today

· Flu vaccine today

· Use an approved car seat for the height and weight of your child every time she rides in a vehicle. Your child must be in a car seat in the back seat until age 4.   After age 4, your child must ride in a car seat or belt-positioning booster seat in the back seat until he or she is 4 feet 9 inches  or taller.

· Be a good role model for your child. Do not talk or text on your cellphone while driving.

· Keep all knives, guns or other weapons out of your child’s reach. Store guns and ammunition in different parts of your house.

· Keep all medicines, cleaning supplies and poisons out of your child’s reach

· Teach your child the dangers of running  into the street. You will have to remind him or her often.   Teach your child to be careful around all dogs, especially when the dogs are eating.

· Talk to your child about not talking to or following strangers. Also, talk about “good touch” and “bad touch.”  

· Teach your child good hygiene and how to wash his or her hands. Teach your girl to wipe from the front to back