Young woman with a urinary tract infection and abdo pain - Essay Example

?Evidence-based medical practices (EBP) have proven helpful in accurate diagnosis and management of most diseases and conditions. The practices entail the use of available research and findings to refine and enrich health care services offered. The model systematically evaluates prevailing and valid research findings in answering clinical questions and affording treatment. The integration of evidence-based practices in health care facilities aims at providing external scientific evidence with regard to clinical settings as a way to improve quality of care offered to patients (Brusch, 2011). Advances in research technology, present new evidence on how to approach various human diseases and conditions. Therefore, consulting with recent finding provides timely and effective interventions to clients and patients who otherwise could have missed. Evidence-based practice involves four fundamentals that include formulation of a clinical query, research, and assessment of the information, and establishment of a clinical resolution. By posing a clinically driven and relevant question, health professionals can systematically form a diagnosis and recommend appropriate treatment. Clinical queries often include a description of patient’s indications of illness in order to formulate appropriate approaches for the resolution of the clinical problem. This paper seeks to illustrate the application of evidence-based practices in the comprehensive diagnosis and treatment of a urinary tract infection in a young female patient. In the case study, a young woman presents symptoms, which are indicative of UTI, she complained of abdominal pains, a burning sensation (dysuria) when emptying her bladder and pain in the lower back. In addition, she indicated an increase in the number of times she relieved herself, on examination, she was found to have fever and evidence of vaginal discharge. Although the clinical manifestations did not conclusively distinguish between upper tract infections from lower tract infections, systemic symptoms provided guidance during examination to indicate upper tract infection. This is likely to be more dangerous since unlike the lower tract, which affects the bladder and urethra, upper infections pose a threat to the kidneys and could result in kidney failure in the end if remedial action is not taken. In this case, the symptoms following patient assessment warranted further investigations for a comprehensive diagnosis and management. First, a differential diagnosis was carried out on the young woman that involved assessing the possibility of other underlying conditions or infections. Various pathogenic infections and disease entities mimic clinical manifestations involved in urinary tract infections. Such disease conditions include prostatitis, urethritis, vaginitis, trauma, intra-abdominal abscess, genitourinary tuberculosis, sepsis among others. In addition, several other factors had to be considered, her health history for one was thoroughly investigated. In case if she had had an injury affecting her urinary system or undergoing chemotherapy, this are some of the main reasons why someone of her age would be vulnerable to UTI. Consequently, to make a comprehensive resolution, a thorough examination of all aspects carried out to facilitate an accurate diagnosis on the patient. Since, in spite of the similarity in clinical manifestation, there exist degrees of variation as per the evidence-based treatment. She was examined using PQRST method for pain assessment that provides a platform on which clinical questions were answered systematically; thus ruling out infections and conditions that mimic UTI. She described the pain with respect to its provocation, quality, spread (radiation), severity, and duration. She complained of sharp abdominal pains radiating from the bladder to the lower back and a burning sensation while urinating. Based on this symptoms there is clear evidence to strongly suggest she may be suffering from a UTI, however, it was not a very acute case since that would likely be accompanied by severe fatigue and bouts of vomiting. The radiating pain lasted an instance varying each instance on the degree of severity, and for a definitive diagnosis, laboratory tests were requested on her urine sample in order to assess the possibility of other infections such as Haematuria. The doctors considered therapy based on the symptoms, however while being cognisant of its potential for cost effectiveness, they finally opted for laboratory investigations which are critical in making a comprehensive analysis. Since therapy without a specific prognosis could result in either the patient, being treated for a UTI when she was in reality suffering from something else that has conditions similar to UTIs symptoms like kidney stones and chronic fatigue. Therefore, until doctors make a concrete diagnosis, it is not advisable to commence treatment. These investigations revolved around a urine sample that was collected and preserved. The assessment performed on her was urinalysis, which involved physical, chemical in both qualitative and quantitative tests, and microscopic examinations where qualitative tests were to be reported as positive or negative while quantitative results were determined by the amounts of substance detected. Qualitative tests were used to detect abnormal chemical substance in her urine by use of dipstick infused with appropriate reagents, which are commercially and provide convenient and cost effective means of detecting chemical substances in urine. The young woman’s sample was tested for a variety of substances including proteins, glucose, ketone bodies, bilirubin, blood, pH, nitrites among others. Certain substances that are often not present in urine under normal circumstance, infections that impede normal functions of the urinary system were detected in her specimen. A Urine microscopy; was also carried out, a process that involved centrifuging the urine sample and examining the supernatant fluid under a microscope. Urinary sediments of clinical significance were then identified, reported, and interpreted for diagnosis. The available sediments included red and white blood cells, casts, crystals, bacteria, parasites, yeast and protein matter. While these could portend a different problem altogether –Red Flags or Haematuria and their combined presence, albeit in small quantities made it quite apparent that the patient likely had UTI. In the laboratory report, her urine sample reflected turbidity and a degree of cloudiness attributed to urinary sediments. Turbidity is an indication of WBC or RBC in the urine increased lipiduria or contamination with faecal matter all that point toward the passivity of UTI. The specific gravity and pH of her urine sample showed variations, an indication of nephritis infection. Some bacteria such as E coli produce acid in urine while others such as Proteus produce ammonia making the urine alkaline. Deviation from the normal odour in urine can be attributed to the presence of bacteria, since the young woman presented this further analysis was warranted. Chemical analysis was carried out using dipstick tests, which indicated minimal proteinuria in the case of urinary tract infection. Similarly, the detection of nitrite in urine with leucocyte esterase suggested asymptomatic urinary tract infection as some bacteria convert nitrate to nitrite (Ochei and Kolhatkar2000, p.141). However, specific conditions must be met such as the collection of first morning urine sample, which is required for an ideal detection test. On microscopic examination, the number of red and white blood cells was unusually increased, however, the demonstration of the cells does not distinguish between acute and chronic infection. Most bacteria causing UTI can be easily identified microscopically with the presence of bacteria in a fresh urine sample to indicate infection. Similarly, oval budding structures were demonstrated in the urine sample signifying the presence of yeast cells, confirming candidiasis. Parasites such as E histolytica, Trichomonasvaginalis, and Schistosomahaematobiumcan also could be demonstrated in urine microscopy. Considering the indications of bacterial, further investigations were necessary thus, urine culture was performed on her specimens that contained pus cells, casts, proteins, bacteria, or showing varying pH reactions. Normally this is done to investigate the possibility that a patient may be suffering from cystitis or pyelonephritis (Sobieszczyk n.d., p.7). Culture is important for the identification of microorganism demonstrated in microscopy. In the procedures, the supernatant was inoculated on the surface of the culture solution before incubating it for a pre-set time. Colonies were identified through morphological features and biochemical testing before comparing with known characteristics, and antimicrobial sensitivity tests were done to determine vulnerability of cultured microorganisms. This testing was done to help identify drugs that would work best against the isolated organisms. This was critical as it was done to ensure that patient received effective therapy, by identifying potential resistance among the isolates. The doctors found a wide array of microorganisms, which are prevalent agents of UTI since they colonise the tract's mucosa. Following laboratory investigations, the infection was attributed to a combination of yeast and E coli colonisation. Although E coli are regarded as a commensal in most part of the body, it is the commonest cause of cystitis, pyelitis, and pyelonephritis. During differential diagnosis, several other organisms were considered which normally indicate UTIs such as Proteus mirabilis, Mycoplasma hominis, Neisseria gonorrhoea, and Klebsiellapneumonae (West 2006, p.14). The normal habitat of these bacteria is often the enteric tract, but their transfer to other regions in the body results in colonisation. On enquiry, the doctors concluded likelihood that she had contracted this through poor bathroom habits such as wiping from back-to-front and, which acts to spread pathogenic organisms to the urethra. She had yeast infections caused by Candida albicans resulting in candidiasis as observed in the valvovaginal area, which was characterised by a whitish discharge. The presence of candida species is regarded as common occurrence; however, increase in their number often results infection owing to competition among the colonies. She described her lifestyle as marred with poor eating habits to include foods that foster bacterial colonisation. She indicated her enormous rations of foods and drinks that are rich in fructose, caffeine, and alcohol, which provide an amicable environment for the growth of bacteria and yeast. In addition, she highlighted her low intake of water, which is essential in improving the functionality of the urinary system. Dehydration plays an enormous role in raising stress levels in the kidneys and immune system while hydration assists in the flushing out microorganisms in the urinary system thus, reducing chance of UTI. In UTIs, misuse of antibiotics creates tolerance by organisms leading to resistance and chronic infections. In addition, ingestion too many drugs (self-medicated antibiotics) could have interfered with her kidneys and contributed towards the presence of protein matter in her urine, which was a strong, sign of an infection. Broad-spectrum antibiotics have been indicated to eliminate commensals or reducing some bacteria and promoting the growth of others. This is especially so with urinary tract infections where Candida species are involved in that, medication eliminates organisms important for regulation of others. Similar occurrences are common with some soap, deodorants, and other products known to cause irritation of the mucosa. Such irritation on the mucosa breaks the natural immunological barrier to promote the proliferation of pathogenic organisms and colonisation of the affected regions. Whereas most UTIs resolve spontaneously, in her case this was unlikely owing to the chronic nature of the infection; the doctors thus prescribed the administration of antimicrobials, which have been proved effective in dealing chronic infections. While therapy aims at destroying the offending organisms, relieving symptoms, and preventing complications, the choice of medication and the length of treatment are influenced by the nature of the infection, whether complicated or uncomplicated, and the age of the patient. In addition, considerations for the duration of infection, cost of treatment, and resistance patterns of the causative microorganisms are essential in order to achieve effective treatment. Quinolones are administered in the event of complicated pyelonephritis and culture findings are not available. However, exercising caution is necessary with increased reports of resistance to the drug in the treatment of uncomplicated cystitis. Ciprofloxacin is also indicated as effective in clearing of urinary tract infections (Domino and Baldor2012, p.1375). Having being diagnosed with uncomplicated UTI, a dose of trimethoprim was preferred as first-line drugs since they have little impact on vaginal normal flora, but are effective against E coli infections and cystitis (Arcangelo and Peterson 2006, p.458). As such, the three-day therapy with Bactrim was prescribed instead of a 7-day course of antibiotics, which would have been recommended if the UTI was complicated. Antimicrobial agents used in third-line therapy are determined following culture and sensitivity testing. Candida vulvovaginitisis often cleared by administering traditional treatment strategies comprising of vaginal suppositories or topical creams of nystatin or amphotericin (Crooks and Baur2011, p.463). The azole line of drugs such as fluconazole, ketoconazole among others has also been illustrated as active against yeast infections. Another urine culture was scheduled after she had completed the dosage, in the event the symptoms did not clear, the other option would have been to prescribe the seven-day course. In such a case, the doctors may also decide to administer the next regimen intravenously if the first one was done orally since in some patients the latter proves more effective. Management of complicated UTIs is required for patients presenting systemic signs or with a history of abnormalities with regard to the anatomy and function of the urinary system (Bope, Rakeland Kellerman 2010, p.701). Owing to the risks involved with complicated UTIs, anatomic and functional investigations should be done in order to identify underlying illnesses. Moreover, prolonged courses of therapy are indicated for patients with persistent infections such as chronic bacterial prostatitis. While finding that she was infected with a UTI, which is a serious condition by any standard, was devastating, the doctors reassured the patient that her visiting the hospital was healthy decision. Out of ignorance or embarrassment, many patients hide their symptoms until it is too late and by then the condition has progressed too far for it to be remedied as easily as it was in her case. Thus the positive diagnosis and treatment not only served to prevent the disease from escalating but also made her more aware of the risks resulting from her lifestyle feeding more feeding and hygiene habits. If it had not happened there she would have probably continued wiping back to front in ignorance and probably exposed herself to problems that are more serious. She was advised on lifestyle modification to minimise risks of developing urinary tract infections. Studies indicate that certain contraceptives increase the risk of UTI and thus, alternative forms of contraception should be provided (Epp and Larochelle2010, p.1085). She was directed to monitor her diet by preferring those rich in fibre, fruits, vegetables, and antioxidants that help in reducing susceptibility to UTIs by promote one’s health. Foods to avoid include corn, dairy products, trans fatty acids, and food additives, which have demonstrated to foster bacterial growth in the urinary tract. In addition, she was asked to procure nutrition supplements such as vitamins, omega 3 fatty acids, and probiotics, which work to decrease UTIs by boosting the immune system and restoring vaginal normal flora. Cranberries and blueberries were also advocated for, having been recognised as an alternative in the prevention of UTIs owing to their anti-adherence properties that inhibit the binding of bacteria to the urinary tract (Wang 2013, p.39). It was critical that she understood sanitary routines with regard to wiping since wiping from back-to-front increases the risk of contaminating the urethra with pathogens found within the anus and thus, discouraged. Such contaminations have been attributed to infections by bacteria that are usually normal flora in other parts of the body. She was advised to avoid feminine products that have been proved to irritate the skin or cause allergic reactions. As such, deodorants, powders, indicated soaps should not be used in the genital area as they can irritate the urethra. Similarly, she was advised to avoid sexual relations in the course of treatment period. In addition, her partner was slated in for an appointment in order to undergo treatment as a precaution since men act as reservoirs for Candida species (Mishra and Agrawal2012, p.122). Follow up appointments were also given as measures to check on her response to therapy. The application of confirmed and current data forms the basis of evidence-based practices in resolving clinical investigations. Clinical questions are formulated following assessment of patient symptoms and comparing with known research to seek evidence of how to proceed with diagnosis and treatment. This ensures that quality healthcare services are provided through evaluating other case studies presented in a similar manner. References Arcangelo, V. and Peterson, A. 2006.PharmacotherapeuticsFor Advanced Practice: A Practical Approach, Philadelphia: Lippincott Williams & Wilkins. Bope, E., Rakel, R. and Kellerman, R. 2010. Conn's Current Therapy 2011, Amsterdam: Elsevier Health Sciences. Brusch, J. (2011). Urinary tract infections in females. Medscape Reference. [Online] Available athttp://emedicine.medscape.com/article/233101-overview[Accessed on April 13, 2013] Crooks, R. and Baur, K. 2011.Our Sexuality, Stamford: Cengage Learning, 2011. Print. Domino, F. and Baldor, R. 2012.The 5-Minute Clinical Consult. Philadelphia: Lippincott Williams & Wilkins. Epp, A. and Larochelle, A. 2010, Recurrent Urinary Tract Infection. [Online] Available at http://www.sogc.org/guidelines/documents/gui250CPG1010E.pdf[Accessed on April 13, 2013] Mishra, S. and Agrawal, D. 2012.A Concise Manual of Pathogenic Microbiology, New Jersey: John Wiley & Sons. Ochei, J. and Kolhatkar, A.2000 Medical Laboratory Science: Theory and Practice, New York: Tata McGraw-Hill Publishing Company Ltd. Sobieszczyk, M. n.d. Urinary Tract Infections. [Online] Available at http://www.columbia.edu/itc/hs/medical/pathophys/id/2009/utiNotes.pdf[Accessed on April 13, 2013] Wang, P. 2013, The Effectiveness of Cranberry Products to Reduce Urinary Tract Infections in Females: A Literature Review.UrolNurs.33 (1):38-45. West, K. 2006. Urinary Tract Infections, New York: The Rosen Publishing Group. Read More