WASHBURN UNIVERSITY



Tracy HillWASHBURN UNIVERSITYSCHOOL OF NURSINGNU 513 Advanced Pharmacology: PediatricsOn-line Case Study #2 (10 points)Shannon is a 10 year old girl presenting to the clinic with a 7 day history of burning on urination. Yesterday her urine appeared bloody and she told her mother about her symptoms. Her mother states she has never had this problem before and she is concerned that this is her daughter’s first menstrual cycle. Associated signs and symptoms include lower pelvic pain, frequency and urgency. The patient is on valproic acid suspension for juvenile myoclonic epilepsy diagnosed when she was 7 years old. Her dose is 7.5 ml tid (250mg/5ml). Her last blood work for therapeutic level was one month ago and was within normal limits. She has no known allergies to medications. Her physical exam reveals a well developed, well nourished female in Tanner Stage 2. Her physical exam is unremarkable. The patient lives with her nuclear family of mother, father and two twin younger brothers aged 6. 1. List your three differential diagnoses. What is your priority diagnosis? Provide rationale. (3 points)Differential Diagnoses: 1) Cystitis/ Lower Urinary Tract Infection, 2) Pyelonephritis (Upper Urinary Tract Infection), 3) Onset of menses.Priority diagnosis = Cystitis/ Lower UTI. Cystitis occurs more frequently in females than males. It is an infection of the lower urinary tract, including the ureters, bladder and urethra. The most common signs and symptoms are urinary frequency, urgency, burning, dysuria and sometimes hematuria. Patients may also have lower abd pain/pelvic pain. The patient has a 7 day history of burning on urination and she reported yesterday that her urine appeared bloody. She also reports lower pelvic pain and frequency. 2. What diagnostics would you order to support your priority diagnosis? Provide rationale. (3 points)Urinalysis, culture if indicated (UACI) – Urine culture remains the criterion standard for the diagnosis of UTI. Collected urine should be sent for culture immediately (Medscape, 2011). The UA will tell us if this is cystitis. A urine culture will identify bacteria and make sure we are treating with the appropriate antibiotic. Usual etiology of UTI is E. Coli.CBC – (complete blood count) The WBC count usually is elevated in patients with complicated UTI’s. The WBC count may or may not be elevated in patients with uncomplicated UTI. Complete metabolic profile (COMP) - Patients with complicated UTI’s may have anemia, which is observed in 40% of patients with perinephric abscesses; some patients have finding of electrolyte abnormalities (Medscape, 2010)I would also check a valproic acid level for completeness. Side effects of valproic acid include n/v/d and abdominal pain, so would want to make sure levels are therapeutic and also not toxic.3. What pharmacological treatment would you recommend for this patient? (4 points)Bactrim (Trimethoprim-sulfamethoxazole) (TMP-SMZ); 40mg/200mg/5ml; 12mg/kg/day; divided twice a day for 14 days. TMP-SMZ has been given an “A” rating in the 1999 IDSA guidelines for treating UTI’s (Medscape, 2010). I would also consider Phenazopyridine (Pyridium) – non-prescription relief of dysuria; 200mg po TID for 2 days prn dysuria.I would educate the patient/parent on wiping front to back with urination; drink plenty of fluids; finish antibiotics. No bubble baths due to increased risk for UTI. Follow-up after completion of antibiotics to recheck UA. Return for worsening. Any questions?ReferencesEdmunds, M. W., & Mayhew, M. S. (2009). Pharmacology for the primary care provider (3rd ed.). St.Louis, MO: Mosby. ................
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