Urinary Tract Infection
PATIENT PRESENTATION
Pt KMM was an 86 year old female who presented in the emergency room with mental status changes as noted by the nurses and technicians at her nursing home. Per the nursing home report, KMM was normally alert and oriented to person, place, and time. Over the past two days, KMM had exhibited intermittent periods of confusion to both place and time. Vitals were stable in the Emergency Room – BP 146/74, HR 90, RR 15, Temperature 37.9, Oxygen saturation 97% on room air. Patient’s history included hypertension, type 2 diabetes, and a right knee replacement five years prior. Patient was continent of urine and stool, but complained of urinary frequency and mild discomfort with urination. In the ER, KMM was alert and oriented to self and place only. She had no complaints of pain, and denied shortness of breath. Patient was ambulatory with walker and one person observation. Blood cultures and urinalysis and urine culture were sent. CT of the brain was also ordered to evaluate the mental status changes.
DIFFERENTIAL DIAGNOSIS
Stroke, aortic aneurysm, hyponatremia, metabolic encephalopathy, meningitis, west Nile fever/encephalitis, infection
DIAGNOSIS
KMM’s urinalysis came back showing an elevated white blood cell count at greater than 50. The specific gravity and pH of the urine were normal, but the sample did show cloudiness. Blood cultures were negative. Her CBC showed a WBC count of 12,000. A CT showed no changes in the brain.
TREATMENT
Normal saline at 100cc/hour was started to maintain adequate hydration of the patient. When the cultures returned, it was determined that the patient had a urinary tract infection. IV ciprofloxacin and IV metronidazole were started for the first 48 hours, and then the patient was switched to oral medication for a 14-day course of treatment. The IV fluids were discontinued once KMM was able to maintain sufficient hydration orally.
OUTCOME
KMM was successfully discharged from the hospital four days after her admission. On discharge, she was instructed to complete her two-week course of oral antibiotics (ciprofloxacin and metronidazole). The patient had a cleared mental status and was oriented to person, place, and time at the time that she returned to her nursing home. She was instructed to maintain adequate hydration with oral fluid intake. Other preventative measures that KMM was instructed on included wearing cotton underwear and wiping from front to back after using the bathroom.
Case created by Kathleen Manty, 2012.