A 55-year-old woman presents to the office with bloody urine and dysuria of 12-hour duration. She was recently married and has never had similar symptoms. She denies chills a

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Case #1:  A 55-year-old woman presents to the office with bloody urine and dysuria

of 12-hour duration. She was recently married and has never had similar
symptoms. She denies chills and fever. On physical examination she is afebrile, has normal vital signs, and has mild tenderness in the midline above the pubis. Her urinalysis shows too many to count (TNTC) red blood cells.se

1. What is the definition of bacteriuria?
2. What additional history do you need to make a diagnosis?
3. What diagnostic studies would you order and why?

Case #2:  A 23-year-old woman was married a year ago. Since then, she has experienced five attacks of acute cystitis, all characterized by dysuria, increased frequency, and urgency. Each infection responded to short-term treatment with trimethoprim sulfamethoxazole. The recurrences occurred at intervals of 3 weeks to 3 months following completion of antibiotic therapy. For the past two days, the woman has been experiencing acute flank pain, microscopic hematuria, dysuria, increased frequency, and urgency.

Her vital signs are T = 37.9°C, P = 106, R = 22, and BP = 130/75 mm Hg. Physical examination reveals costovertebral tenderness, mild tenderness to palpation in the suprapubic area, but no other abnormalities.

1. What are possible reasons for this woman’s pain? List possible differential diagnosis and explain each?
2. What diagnostic tests should you order to confirm diagnosis?
3. What are the possible causes of recurrent lower UTIs?
4. What are the differences when comparing prerenal acute renal failure, intrarenal acute renal failure, and postrenal acute renal failure? Give examples of each.

Cite current research findings, national guidelines, and expert opinions and controversies found in the medical and nursing literature to support your position.

 Answer below

Case #1

1.Bacteriuria is the presence of bacteria in urine. Bacteriuria accompanied by symptoms is a urinary tract infection while that without is known as asymptomatic bacteriuria. 

2.frequency, urgency and  suprapubic pain when urinating,fatigue, irritability, malaise, nausea, headache, abdominal discomfort, and back pain.

3.An evaluation of numerous reported studies indicated that the most useful screening tests for significant bacteriuria appear to be a nitrite test (modified by adding nitrate and incubating at 37 C), the triphenyltetrazolium chloride (TTC) test, and microscopic examination for bacteria. A study of 1,151 urine specimens submitted for routine culture showed that microscopic examination of the centrifuged deposit for organisms or pus cells, or both, was a more sensitive test for significant bacteriuria than the modified nitrite test. Microscopic examination detected 98% of 175 urine specimens with significant gram negative bacilluria, and 17 of 20 with significant numbers of gram positive cocci. The false positive rate was 13%. Microscopy may be better than the chemical screening tests in the selection of urine specimens for cultural examination.

Case #2

1.possible reason is the patient is experiencing Pyelonephritis. 

Differential diagnosis:

• Urethritis is defined as infection-induced inflammation of the urethra. The term is typically reserved to describe urethral inflammation caused by a sexually transmitted disease (STD), and the condition is normally categorized as either gonococcal urethritis (GU) or nongonococcal urethritis (NGU).
• Urinary tract infections (UTIs) are common in females, accounting for over 6 million patient visits to physicians per year in the United States. Cystitis (bladder infection) represents the majority of these infections (see the image below). Related terms include pyelonephritis, which refers to upper urinary tract infection; bacteriuria, which describes bacteria in the urine; and candiduria, which describes yeast in the urine.
• Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).

2.Urinalysis and urine culture confirm the diagnosis of acute pyelonephritis. The consensus definition of pyelonephritis established by the Infectious Diseases Society of America (IDSA) is a urine culture showing at least 10,000 colony-forming units (CFU) per mm3 and symptoms compatible with the diagnosis.

3.What Causes Recurrent UTIs?

• Being in a nursing home or hospital.
• Diabetes.
• Kidney or bladder stones.
• Having a catheter.
• Previous urinary tract surgery.
• Sexual activity.
• Certain types of birth control, including use of diaphragm or spermicide.
• Menopause.

4.Prerenal: decreased renal perfusion (often from hypovolemia) leading to a decrease in GFR; reversible. 

• Ex:Burns.
• Conditions that allow fluid to escape from the bloodstream.
• Long-term vomiting, diarrhea, or bleeding.
• Heat exposure.
• Decreased fluid intake (dehydration)
• Loss of blood volume.

Intrarenal: intrinsic kidney damage; ATN most common due to ischemic/nephrotoxic injury.

Ex:

• severe bleeding.
• shock.
• renal blood vessel obstruction.
• glomerulonephritis.

Postrenal: extrinsic/intrinsic obstruction of the urinary collection system.

• Ex: Kidney stones . Kidney stones most often develop in the ureters
• An enlarged prostate ( benign prostatic hyperplasia, or BPH ).
• A bladder that doesn't empty properly.
• Blood clots in the ureters or urethra.
• Cancer of the prostate, cervix, or colon.