Chronic Urinary Tract Infection SOAP Note
Chronic Urinary Tract Infection
Overview
The 74-year old male patient is a retired officer who is presenting symptoms of urinary frequency, incontinence, dribbling, as well as lower abdominal fullness, which is an indication of frequent urinary tract infection. A UTI occurs in any of the parts of the urinary system —urethra, bladder, kidney, and ureter (Papadakis et al., 2019). The infections often involve bladder and urethra (lower urinary tract). Also, UTIs can occur whenever bacteria enters the patient’s urinary tract via the urethra and start to reproduce in the bladder. Even though the urinary system has been designed to block microscopic intruders, there could occasionally be a failure in the defense; hence, the bacteria grows into a full-blown urinary tract infection. Infections limited to the bladder can be annoying and excruciating. However, serious health effects could occur if the UTI is spread to the kidneys leading to hypertension. Thus, the diagnosis is a frequent urinary tract infection.
Subjective Data
The clinical presentation of UTI signs and symptoms differ extensively in occurrence and intensity. The additional subjective data that the patient will share include urinary incontinence, dysuria, urinary urgency or frequency, hematuria, nocturia, lower back pain, supra-pubic pain, cloudy urine, or foul-smelling urine (Dunphy et al. 2019). The reported symptoms can happen in any combination. Urethritis is a rare occurrence in men; if it is untreated or treated defectively, there will be complications like urethral strictures, fissures, periurethral abscess, and urethral diverticuli.
Objective Data
The physical exam is negative for any abnormalities and reveals a regular breathing rate, but a hypertensive crisis since the blood pressure is extremely high. An additional physical exam will include clean-catch and mid-stream sample for the urinalysis that will reveal the patient’s urinary tract system’s infectious process. The urinalysis could exhibit either hematuria, cloudy appearance, elevated nitrite levels, alkaline pH, leukocyte esterase (detection of pyuria of higher than ten leukocytes/HPF), urine red blood cells, sediments, mucus, WBCs, or overgrowth of bacteria (Sydney et al. 2018). Notably, Enterobacteriaceae converts the urinary nitrates into nitrites, creating positive results on the analysis of the urine dipstick if present in large numbers of more than 100,000 organisms per milliliter. However, staphylococci do not convert the substrate and cannot be detected by the test. Besides, false-positive urinary nitrite tests can lead to the presence of analgesic phenazopyridine in the urinary tract. Also, urine culture and urine sensitivity can be ordered to determine and speciate the sensitivity of causative organisms to particular antibiotic therapy. The IC Patients may also present with the regular need for frequent urination due to reduced bladder capacity, which can happen up to 60 times daily under extreme cases. The other clinical data that can be assessed include symptoms like discomfort and pain in the abdominal area holding the bladder.
National Guidelines/Evidence
The 2019 America Urological Association guideline can be used in the evaluation as well as the management of patients with recurring UTIs. The aim is averting inappropriate usage of antibiotics, decreasing risks of antibiotics resistance, reducing adverse consequences of the use of antibiotics, non-antibiotics and antibiotics prevention strategies, and improving clinical outcomes (Anger et al., 2019). The American Family Physician also offer clinical guidelines on urinary tract infections and related medical issues, and the urine dipstick tests. The preliminary targeted history comprises features of local causes (urethral or vaginal irritation), risk factors for the complicated UTIs, and pyelonephritis symptoms. Any recurrent symptoms or complicating features warrant a patient history, physical examination, urine culture, and urinalysis (Michels & Sands, 2015). The findings from the study’s secondary assessment, designated lab tests, and focused imaging studies can permit a physician to advance through rational evaluations and establish the causes or suitable referrals.
The urinalysis with microscopy has been demonstrated as an essential tool for clinicians. Urine dipstick tests and microscopy are valuable for diagnosing some systemic and genitourinary conditions. Furthermore, in 2014, an AFP article presented a sequence of cases illustrating how primary healthcare physicians use urinalysis under varied clinical situations. For patients with suspect microscopic hematuria, urine dipstick tests can reveal the blood presence, and the test results ought to be verified with the microscopic examination (Sharp et al. 2014). This microscopic evaluation includes cystoscopy, renal function tests, and urinary tract imaging. In patients with the ureteral stent, urinalysis only cannot institute the UTI diagnosis. Plain radiography of the bladder, kidneys, and ureters can identify stents and is ideal than computed tomography. The USPSTF and Infectious Diseases Society offer recommendations against screening for asymptomatic bacteriuria among adult men with the exception of before scheduled urologic procedures
Diagnostic Tests
Some several tests and procedures are used in diagnosing urinary tract infections. First, the diagnosis can be made based on the subjective patient complaints as well as the clean-catch midstream sample that shows the bacteria, notably if exceeding 100,000.0 organisms per milliliter of similar morphology (Burton & Ludwig, 2014). The analysis of urine samples for lab analysis for the detection of red and white blood cells plus bacteria. The patient is instructed first to wipe the genital opening with the antiseptic swab and collect urine midstream to avoid any potential sample contamination, but straight catheterization urine samples obtained using sterile methods are most reliable. Secondly, the urine culture and sensitivities involve growing the bacteria in a lab will reveal the bacteria causing the infection and the most effective antibiotic therapy.
Though the urine culture is considered as the gold standard with the utmost sensitivity for the UTI laboratory confirmation, the urinalysis with microscopy can be helpful as it offers rapid results. Urinalysis indicates pyuria (more than ten neutrophils/ HPF on the microscopic examination) and the presence of red blood cells (South-Paul et al., 2020). Even though the diagnosis is made clinically and urinalysis, the urine culture indicates if complicated infections are suspected, presence of atypical symptoms, or whether symptoms recur or persist in one month of receiving an empirical antibiotic therapy course and need for a new treatment regimen. Since the patient has frequent infections that could be instigated by abnormalities in the urinary tract, the ultrasound, CT scan, or MRI can be conducted. Lastly, due to the recurrent UTIs, the physician can also perform a male cystoscopy.
Differential Diagnosis
The differential diagnosis of benign prostatic hypertrophy, prostatitis, pyelonephritis, and urinary tract stones should be explored. First, the BHP symptoms of obstructed urine flow could occur, but the UTI symptoms are exceptional, or else obstruction can lead to UTI development. The differentiating tests include elevated PSA, which suggests the presence of hyperplasia. The enlargement and firm prostate detected on a digital rectal examination help to verify the diagnosis (Hollingworth, 2016). Secondly, prostatitis commonly presents with obstructed urine flow symptoms and rectal pain, but the urinary frequency and dysuria can occur. The differentiating tests revealing boggy and tender prostate on digital rectal examination suggest prostatitis. Next, pyelonephritis is often a UTI complication, but could with no UTI history and can be shown by costovertebral angle pain and tenderness on physical examination. However, the WBC casts presence on the urinalysis tests indicate pyelonephritis. The urinary tract stones can lead to damage of the urinary epithelium and dysuria; but, they also trigger pain. The history of the formation of risks can help in identifying risks. The CT and Intravenous will detect the presence of the urinary tract stones. Lastly, patients with lower UTI can differ from upper UTI as they do exhibit sepsis signs like chills and fever, WBC casts in the urine is a reflection of the neutrophils passage via the renal tubules or experience costovertebral, flank and angle tenderness on the examination. The UTI diagnostic criteria is a urine culture demonstrating higher than 10^2 CFU/mL per single and predominant organism in patients with symptoms explicit to the urinary tract.
Treatment Plan
Pharmacological antimicrobial management is the pillar of UTI treatment. Various oral agents are used for UTI treatment. The epidemiological investigation has discovered rising resistance rates in E coli isolates to sulfonamides and ampicillin, including TMP-SMX. However, a small proportion of the isolates are resistant to nitrofurantoin that is known to concentrate in the urine. Also, nitrofurantoin is effective against most gram-positive cocci, while other uropathogens like Klebsiella, Proteus, and Enterobacter are highly resistant. Both nitrofurantoin and TMP-SMX could be used as empiric therapy for uncomplicated UTI only (Dunphy et al. 2019). The fluoroquinolones have great efficacy against majority uropathogens, but their growing use as first-line therapy has been related with steadily rising resistance rates.
A seven-day course of nitrofurantoin will be used for a patient with recognized sulfa allergies or previous antibiotic use in the past three months for maximum efficacy. The prescribed medicine is Macrodantin or Furadantin dosage of 100 mg 2 times daily for seven days. Although the prescribed antibiotic treatment is adequate for relieving dysuria, some medications can also be prescribed for initial days to reduce pain and discomfort. An effective treatment plan will involve anticholinergics that produce antispasmodic effects, comprising atropine (Donnatal), propantheline (Pro-Banthine), oxybutynin (Ditropan), or hyoscyamine (Cystospaz). Finally, complementary herb therapy of standardized cranberry extract capsules 300 to 400 mg PO 2 times every day will prevent bacteria adherence to the bladder wall and inhibit adhesion of E. coli to uroepithelial cells.Healthy people 2020
One of the primary goals of Healthy people 2020 is preventing, reducing, and eventually eliminating healthcare-associated infections obtained while receiving treatment for surgical or medical conditions. The commitment of the U.S. HHS Department is preventing HAIs with high-priority objectives aimed at addressing CLABSI and MRSA infections. The major kinds of HAIs are catheter UTIs, Clostridium difficile, Pneumonia, as well as surgical site and bloodstream infections. HAIs are the leading cause of health complications that arise in a continuum of health care and can be readily transmitted between health facilities.
Evaluation
After the conclusion of the prescribed antibiotic treatment, there is a need to obtain follow-up cultures to guarantee complete suppression of the pathogens in patients with a history of recurrent UTIs or disposed of complicated UTIs. Chronic UTI can be prevented via prophylactic treatment either daily, or after sexual intercourse, however, this should be conducted after all alternatives to eradicate the UTI causative factors have been explored wholly.
Patient and Family Teaching
Patient education focuses on preventing the recurrence of UTI by advising the patient to follow several guidelines: Also, the patient teaching notifies the patient on adverse reactions to the medicine, including nausea anorexia, abdominal discomfort, and vomiting. The patient should notify the physician of the occurrence symptoms like flank pain, hematuria, fever, and no response to the prescribed treatment. The prescribing conditions are the drugs that should be taken with food, and the medicine can cause darkening of the urine. The patient should maintain a diary of infections and responses to treatment for reviewing annually with health professionals and tracking medication-linked problems (McAninch & Lue, 2020). The patient should complete their full antibiotic therapy course even after the symptoms subside and increase their fluid ingestion to eight 8-ounce glasses daily to flush out bacteria.
Billing Codes
The Z87.440 is the billable code used in specifying a medical diagnosis of the patient’s personal history of UTIs. The Z87.440 code is valid for 2020 for compliance with HIPAA transactions. The ICD-10-CM Z87.440 code can also be used in specifying conditions and terms like chronic urinary tract infection or febrile urinary tract infection or recurrent urinary tract infection or urinary tract infection history.
Follow up and Referral
The patient should follow up with the midstream and clean-catch samples for the urinalysis for evaluating for the presence of WBCs or urine culture plus the sensitivity for recurrent UTIs. Since the patient has frequent recurrences, he could be referred to doctors who specialize in urinary disorders (urologist) for an evaluation. To prepare for the appointment, the patient should collect the urine specimen, list symptoms, medications, and supplements.
References
Anger, J., Lee, U., Ackerman, A. L., Chou, R., Chughtai, B., Clemens, J. Q., Hickling, D., … Chai, T. C. (August 01, 2019). Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. Journal of Urology, 202, 2, 282-289.
Burton, M., & Ludwig, L. J. M. (2014). Fundamentals of nursing care: Concepts, connections & skills. Philadelphia, PA: F.A. Davis Company.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.
Hollingworth, T. (2016). Differential diagnosis in obstetrics and gynecology: An A-Z.
Boca Raton, FL: CRC Press.
McAninch, J. W., & In Lue, T. F. (2020). Smith & Tanagho’s general urology.
Michels, T. C., & Sands, J. E. (January 01, 2015). Dysuria: Evaluation and Differential Diagnosis in Adults. American Family Physician, 92, 9, 778-792.
McAninch, J. W., & In Lue, T. F. (2020). Smith & Tanagho’s general urology. New York: McGraw-Hill
Papadakis, M. A., In McPhee, S. J., & In Bernstein, J. (2019). Quick medical diagnosis & treatment 2019. New York, N.Y.: McGraw-Hill Education LLC.
Sharp, V. J., Lee, D. K., & Askeland, E. J. (January 01, 2014). Urinalysis: case presentations for the primary care physician. American Family Physician, 90, 8, 542-7.
South-Paul, J. E., In Matheny, S. C., & In Lewis, E. L. (2020). Current diagnosis & treatment: Family medicine. New York: McGraw-Hill Medical.
Sydney, E., In Weinstein, E., & In Rucker, L. M. (2018). Handbook of outpatient medicine. Cham, Switzerland: Springer.
U.S Preventive Services Task Force (September 24, 2019). Screening for Asymptomatic Bacteriuria in Adults: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Annals of Internal Medicine, 149, 1, 43-47.