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Comprehensive UTI (Urinary Tract Infection) Case Study

Patient Chart

Patient Name: Mary Elizabeth James

Date of Birth: 02/09/1968

Age: 57

Gender: Female

Medical Record Number: 20250316

Date of Admission: 03/16/2025

Primary Care Provider: Dr. Susan Miller

Chief Complaint (CC)

“I’ve had painful urination and frequent urges to go to the bathroom for the last two days.”

History of Present Illness (HPI)

Mary James is a 57-year-old female who presents with complaints of dysuria (painful urination), urinary frequency, and urgency. These symptoms have been present for the past 48 hours and have progressively worsened. She describes a burning sensation during urination, as well as the feeling of needing to urinate frequently, with only small amounts of urine being passed each time. She also notes mild lower abdominal discomfort but denies fever, chills, or hematuria.

The patient reports that she had a similar episode of urinary symptoms about 6 months ago, which was treated with antibiotics. She denies recent changes in sexual activity or new sexual partners.

Past Medical History (PMH)

·
Recurrent Urinary Tract Infections (UTIs) – several episodes over the last 5 years

·
Hypertension – diagnosed 8 years ago, controlled with medication

·
Type 2 Diabetes Mellitus – diagnosed 5 years ago, controlled with Metformin

·
Osteoarthritis – diagnosed 10 years ago, controlled with NSAIDs

·
No known history of kidney stones or bladder conditions.

Surgeries & Procedures

·
Hysterectomy (5 years ago, due to fibroids)

·
Knee arthroscopy (3 years ago)

Allergies

·
Penicillin – Rash

Medications

· Metformin 1000 mg twice daily for type 2 diabetes

· Lisinopril 10 mg daily for hypertension

· Ibuprofen 200 mg as needed for osteoarthritis pain

Family History (FH)

·
Father: Deceased, 75, with a history of heart disease and hypertension

·
Mother: Alive, 82, with a history of hypertension and type 2 diabetes

·
Sister: Alive, 59, with a history of breast cancer

·
Paternal Grandmother: Died of complications from diabetes at age 80

Social History (SH)

·
Smoking: Non-smoker

·
Alcohol: Occasional drinker (1-2 drinks per week)

·
Drug Use: Denies illicit drug use

·
Occupation: Retired school teacher

·
Living Situation: Lives with her husband, independent in activities of daily living

Review of Systems (ROS)

·
General: No fever or weight loss

·
Cardiovascular: No chest pain, palpitations, or dizziness

·
Respiratory: No shortness of breath or cough

·
Gastrointestinal: No nausea, vomiting, or abdominal pain

·
Genitourinary: Dysuria, urinary frequency, and urgency, no hematuria

·
Neurological: No headaches or visual changes

·
Musculoskeletal: Mild joint pain due to osteoarthritis, no new symptoms

Physical Assessment Findings

Vital Signs:

· Temperature: 98.5°F (36.9°C)

· Heart Rate: 78 bpm, regular

· Respiratory Rate: 16 breaths/min

· Blood Pressure: 128/80 mmHg

· Oxygen Saturation: 98% on room air

General Appearance: Overweight female, alert and oriented, appears slightly uncomfortable due to dysuria

Cardiovascular: Regular rate and rhythm, no murmurs or gallops

Respiratory: Clear to auscultation bilaterally, no wheezing or crackles

Abdomen: Soft, non-tender, no hepatosplenomegaly, mild lower abdominal discomfort

Genitourinary: Positive for suprapubic tenderness, no external genital lesions, no costovertebral angle tenderness

Neurological: Alert and oriented, no focal deficits


Laboratory Results

Urinalysis

Test

Result

Reference Range

Appearance

Cloudy

Clear

Color

Yellow

Pale yellow to amber

pH

7.0

4.5-8.0

Protein

Negative

Negative

Glucose

Negative

Negative

Ketones

Negative

Negative

Blood

Negative

Negative

Leukocyte Esterase

Positive (+)

Negative

Nitrites

Positive (+)

Negative

Specific Gravity

1.015

1.005-1.030

Bacteria

Present

Negative

Complete Blood Count (CBC)

Test

Result

Reference Range

White Blood Cell Count (WBC)

9.0 x10³/µL

4.0-11.0 x10³/µL

Hemoglobin (Hgb)

13.5 g/dL

12.0-16.0 g/dL

Hematocrit (Hct)

41%

36-46%

Platelets (Plt)

250 x10³/µL

150-450 x10³/µL

Basic Metabolic Panel (BMP)

Test

Result

Reference Range

Sodium (Na)

138 mEq/L

135-145 mEq/L

Potassium (K)

4.1 mEq/L

3.5-5.1 mEq/L

Chloride (Cl)

104 mEq/L

98-107 mEq/L

Bicarbonate (HCO₃)

24 mEq/L

22-28 mEq/L

Blood Urea Nitrogen (BUN)

12 mg/dL

7-20 mg/dL

Creatinine (Cr)

0.8 mg/dL

0.6-1.2 mg/dL

Glucose (fasting)

96 mg/dL

70-99 mg/dL

Urine Culture & Sensitivity

·
Organism: Escherichia coli (E. coli)

·
Antibiotic Sensitivities:

· Amoxicillin: Sensitive

· Trimethoprim-Sulfamethoxazole (Bactrim): Resistant

· Nitrofurantoin: Sensitive

· Ciprofloxacin: Sensitive

© 2025 NotesPRN. All rights reserved.

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