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

Complete Blood Count (CBC)

Basic Metabolic Panel (BMP)

Urine Culture & Sensitivity

• Organism: Escherichia coli (E. coli)
• Antibiotic Sensitivities:
  • Amoxicillin: Sensitive
  • Trimethoprim-Sulfamethoxazole (Bactrim): Resistant
  • Nitrofurantoin: Sensitive
  • Ciprofloxacin: Sensitive

Nursing Diagnoses

1. Acute Pain related to inflammation and irritation of the urinary tract as evidenced by the patient’s complaints of dysuria and lower abdominal discomfort.
2. Impaired Urinary Elimination related to UTI as evidenced by urinary frequency, urgency, and burning sensation during urination.
3. Risk for Fluid Volume Deficit related to frequent urination and reduced fluid intake due to discomfort.
4. Risk for Infection related to recurrent UTIs and potential for progression to pyelonephritis.

Plan of Care (Interventions & Rationale)

• Administer antibiotics (e.g., Nitrofurantoin or Amoxicillin) as prescribed based on urine culture and sensitivity results. To treat the infection and reduce symptoms.
• Encourage increased fluid intake (e.g., 8 glasses of water per day) to flush out the bacteria from the urinary system. To assist in clearing the infection and prevent further complications.
• Monitor urine output and characteristics, ensuring no signs of worsening infection, such as hematuria or foul-smelling urine. To assess the effectiveness of treatment.
• Provide pain relief with analgesics (e.g., acetaminophen or phenazopyridine) to manage dysuria. To enhance comfort and improve patient well-being.
• Educate patient on proper hygiene (wiping front to back, urinating after intercourse) to prevent recurrent UTIs. To reduce the risk of future infections.
• Monitor for signs of systemic infection (fever, chills, flank pain) and report any changes immediately. To identify potential complications such as pyelonephritis.

Evaluation & Follow-Up

• Evaluate response to antibiotics by reassessing symptoms (dysuria, frequency, urgency) in 48-72 hours. If symptoms do not improve or worsen, consider further investigations for complicated UTI.
• Follow-up urine culture in 1 week to ensure eradication of infection.
• Repeat urinalysis if symptoms persist or worsen.

Discharge Plan

• Discharge on antibiotics (e.g., Nitrofurantoin 100 mg twice daily for 5-7 days) with instructions for completing the full course.
• Provide education on UTI prevention strategies, such as hydration, appropriate hygiene practices, and avoiding bladder irritants like caffeine and alcohol.
• Encourage follow-up with primary care provider in 1-2 weeks for evaluation of UTI resolution and further management if recurrent.