Upper Urinary Tract Case Studies

CASE 1
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A 67-year-old man complains of urinary obstruction and retention. He is diagnosed with benign prostatic hyperplasia, and urinary bladder catheterization is utilized to temporarily relieve the obstruction. He then undergoes a transurethral resection of his enlarged prostate gland. Following the surgery, an indwelling urinary bladder catheter attached to a closed drainage system is put in place. The patient develops a fever to 38ºC two days later, and on the third postoperative day, he becomes confused and disoriented and has a shaking chill. The patient's vital signs (on the third day) are T = 39 C, P = 120, R = 18, and BP = 90/40 mmHg. On physical examination, he knows his name but is disoriented as to time and place. His heart, lungs, and abdomen are normal, but there is mild costovertebral tenderness over the area of the left kidney.

Question 1.1: What tests would you order to help resolve this case?

Question 1.2: What is your diagnosis?

Question 1.3: What is the most likely etiology of this infection?

Question 1.4: What is the most likely causative agent of this infection?

Question 1.5: How should this patient be treated?

CASE 2

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A 24-year-old man experiences a brief period of dysuria accompanied by some frequency and urgency. These symptoms subside after a couple of days so he does not seek medical treatment. A few days later, however, he suddenly develops fever, chills, and a somewhat more irritating dysuria. This time the dysuria is not accompanied by noticeable urgency and frequency but, because the fever persists, he goes to see his physician. Except for the fever, his vital signs are normal. Upon physical examination, he is found to have extreme tenderness in his prostate by digital rectal examination. The prostate feels quite tense. He does not have any noticeable costovertebral angle tenderness, nor are there any other notable physical abnormalities. He says that he has not had any previous incidents that produced symptoms like the ones he has been experiencing over the past few days.

Question 2.l: What is your preliminary diagnosis?

Question 2.2: How can you confirm this diagnosis?

Question 2.3: How do you suppose this infection came about?

Question 2.4: What are the most common causative agents of this disease?

Question 2.5: What is the prevalence of this disease and what groups are most susceptible?

Question 2.6: How should this case be treated?

CASE 3

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A 27-year-old G2 P1 woman who is in her 6th month of gestation suddenly develops an obvious fever and shaking chills, along with nausea and vomiting. She also has some dysuria with urgency and frequency, but she did not notice any urinary symptoms prior to the onset of fever and chills. Shortly after the fever and chills appear, she develops excruciating flank pain, becomes concerned, and comes to see you for advice. Her vital signs are: T = 39.5ºC, P = 115, R = 18, and BP = 110/70 mm Hg. Physical examination reveals marked tenderness on deep pressure in both costovertebral angles, but there are no other remarkable findings. The fetal heart tones are present at a rate of 130 to 140/minute.

Question 3.1: What is your preliminary diagnosis and how can you confirm it?

Question 3.2: What is the differential diagnosis for these symptoms?

Question 3.3: Do the lab results confirm your preliminary diagnosis? What is the most likely complication that might occur with this disease and is there any reason to think that it has happened in this case?

Question 3.4: How did this patient's current condition come about? What predisposing factors(s) die she have?

Question 3.5: What is the most likely causative agent and how should this case be treated?

Question 3.6: Should the patient be checked for possible alternative causes of the current problem?

CASE 4

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A 56-year-old man has experienced seven distinct incidents of cystitis over the previous 13 months. Each incident was characterized by mild dysuria, along with some frequency and urgency. Each was diagnosed as cystitis by detection of Gram negative bacilli in his urine, with urine counts ranging from 103 to 105 bacterial cells/mL. No efforts were made to identify the causative agents in the first two incidents, but in the other five, the lab managed to isolate the same strain of Proteus mirabilis from a urine specimen. A brief course of antibiotic treatment appeared to be effective in each incident, as the noticeable symptoms always subsided quickly. Nevertheless, the man is tired of these repeated incidents and goes to see if there is anything else his physician can do for him. A detailed history is taken, in which he indicates that he has sometimes experienced mild lower back pain during the past year or so, even though he had no prior history of this complaint. He may also be experiencing occasional perineal discomfort based on the signs and symptoms that he describes, but he cannot recall any other unusual problems. The man has no urinary symptoms at present, and the physical examination is entirely unremarkable. His vital signs are normal. There is no evidence of costovertebral angle tenderness and his prostate feels reasonably normal in size and consistency on palpation by digital rectal examination.

Question 4.1: What is your preliminary diagnosis?

Question 4.2: How can you confirm your diagnosis?

Question 4.3: Do the lab results support your diagnosis?

Question 4.4: How should this condition be treated?

Question 4.5: How can Proteus be identified in the lab?

Question 4.6: What is the differential diagnosis for this man's condition? (What if the culture had been negative?)

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