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I HUMAN CASE STUDY WEEK*7 16 YEARS OLD
HEIGHT/WEIGHT: 5'4" (163 CM), 125 LBS (56.8
KG)CHIEF COMPLAINT: “I’M PEEING A LOT AND IT
HURTS.”LOCATION: OUTPATIENT CLINIC WITH X-
RAY, ECG, AND LAB SERVICES
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I HUMAN CASE STUDY WEEK*7 16 YEARS OLD HEIGHT/WEIGHT: 5'4" (163 CM), 125 LBS (56.8 KG)CHIE, Exams of Nursing
I HUMAN CASE STUDY WEEK*7 16 YEARS OLD HEIGHT/WEIGHT: 5'4" (163 CM), 125 LBS (56.8 KG)CHIEF COMPLAINT: “I’M PEEING A LOT AND IT HURTS.”LOCATION: OUTPATIENT CLINIC WITH X-RAY, ECG, AND LAB SERVICES
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I HUMAN CASE STUDY WEEK*7 16 YEARS OLD
HEIGHT/WEIGHT: 5'4" (163 CM), 125 LBS (56.
KG)CHIEF COMPLAINT: “I’M PEEING A LOT AND IT
HURTS.”LOCATION: OUTPATIENT CLINIC WITH X-
RAY, ECG, AND LAB SERVICES
Age/Sex: 16-year-old female Height/Weight: 5'4", 125 lbs (56.8 kg) Reason for Encounter: Dysuria and increased urinary frequency Setting: Outpatient clinic with diagnostic capabilities
🠀 Key Clinical Considerations
This presentation suggests several possible differential diagnoses:
🠀 Differential Diagnoses (DDx):
- Urinary Tract Infection (UTI) – Most likely given dysuria and frequency
- Sexually Transmitted Infection (STI) – Especially if there's sexual activity history
- Vaginitis (e.g., yeast infection, bacterial vaginosis)
- Interstitial Cystitis – Less common in teens, but worth considering
- Diabetes Mellitus – Could present with polyuria (get a glucose test)
- Pregnancy – If sexually active, rule it out with a pregnancy test
🠀 Case Instructions:
This is an independent assignment—all submitted work must be your own. After completion, i-Human will generate a Performance Overview Report, which: o Doesn’t directly impact your grade. o Is meant to guide your learning. You earn 10 points for full case completion. Refer to your course rubric for expectations regarding the Plan section.
🠀 Additional Tools:
BASIC DDx CASE PLAY SETUP AND INSTRUCTIONS link is provided for guidance.
🠀 History of Present Illness (HPI) – Key Questions to Ask:
- Onset & Duration: o When did the symptoms start? o Are they constant or intermittent?
- Urinary Symptoms: o Is there burning or pain during urination (dysuria)?
o Do you feel the need to urinate more often than usual (frequency)? o Are you waking up at night to urinate (nocturia)? o Any difficulty starting/stopping the stream? o Do you feel like your bladder empties completely?
- Appearance of Urine: o Any blood in the urine (hematuria)? o Is the urine cloudy or foul-smelling?
- Associated Symptoms: o Fever, chills? o Abdominal or back pain? o Vaginal discharge, itching, or odor? o Nausea or vomiting?
5. Sexual History (ask sensitively and privately):
o Are you sexually active? o Do you use protection (e.g., condoms)? o Any history of STIs? o Any new or multiple partners?
- Menstrual History: o When was your last menstrual period? o Are your periods regular? o Any chance you might be pregnant?
- Past Medical History: o History of UTIs or kidney infections? o Any known urinary tract abnormalities? o Any history of diabetes?
Auscultation – Bowel sounds (normal or hypoactive in severe infection) Palpation: o Suprapubic tenderness → Suggests lower UTI o CVA tenderness (costovertebral angle) → Suggests pyelonephritis o Any rebound/guarding → Could suggest more serious intra- abdominal process
- Genitourinary Exam (if appropriate and indicated)
External inspection: o Signs of discharge, erythema, swelling, rash Speculum exam (if sexually active): o Cervical discharge? Friability? Bimanual exam: o Cervical motion tenderness? (may suggest PID) o Uterine/adnexal tenderness?
🠀 Note: Genitourinary and pelvic exams should be performed only if indicated based on sexual history and symptoms, and with proper consent and chaperone.
- Skin
Check for signs of dehydration (dry mucous membranes, decreased skin turgor)
- Neurologic
Lower back pain or numbness/tingling? → Rule out neurologic causes if suspected (rare but relevant in spinal cord pathologies)
🠀 Assessment – Summary Statement Example:
16-year-old female presents with 3-day history of dysuria, urinary frequency, and suprapubic discomfort, without fever, flank pain, or vaginal discharge. No known prior urinary tract infections. Sexually active with inconsistent condom use. Denies nausea, vomiting, or back pain. Urinalysis reveals positive leukocyte esterase, nitrites, and mild hematuria. No CVA tenderness on exam. Vitals within normal limits.
🠀 Differential Diagnosis (with brief rationale):
- Uncomplicated Urinary Tract Infection (Cystitis) – Most likely
Classic signs: Dysuria, frequency, suprapubic pain Positive UA findings (leukocyte esterase, nitrites) No systemic symptoms or CVA tenderness
- Chlamydia or Gonorrhea Urethritis
Test Component Expected Result Interpretation
Blood (Hematuria) + or trace Common with UTI
Protein Trace to mild May be present with infection
Glucose/ketones Usually negative If positive, consider diabetes
Specific gravity
Elevated if dehydrated Not diagnostic, but supportive
🠀 Urine Culture
Organism:E. coli (most common in UTIs)
Sensitivity: Helps determine which antibiotics will work best
🠀 Urine hCG (pregnancy test)
Negative (if pregnancy is ruled out) Positive? → Must consider UTI in pregnancy, or other complications
🠀 STI Testing (if ordered)
Chlamydia NAAT – Negative or Positive Gonorrhea NAAT – Negative or Positive
(If positive → Urethritis/PID should be considered)
🠀 Blood Glucose (if ordered)
Normal: 70–110 mg/dL fasting Elevated: Consider diabetes mellitus
🠀 Final Diagnosis: Uncomplicated Urinary Tract Infection (Cystitis)
🠀 Rationale:
Dysuria and urinary frequency are classic UTI symptoms. No fever, no flank pain, and no CVA tenderness → rules out pyelonephritis. Positive urinalysis (likely showing leukocyte esterase, nitrites, and possibly blood). Patient is a young female, which is a common demographic for uncomplicated cystitis. No significant vaginal symptoms → less likely to be vaginitis. No abnormal discharge or cervical motion tenderness → STI/PID less likely, but STI testing may still be warranted.
🠀 ICD-10 Code (if needed for documentation):
N39.0 – Urinary tract infection, site not specified
- Microscopic hematuria: trace These findings are consistent with a bacterial lower urinary tract infection, most likely due to E. coli, the most common causative organism in UTIs.
A urine pregnancy test was negative, and GC/Chlamydia NAAT testing was ordered due to the patient’s sexual activity. The patient was diagnosed with an uncomplicated cystitis (UTI).
She was prescribed:
- Nitrofurantoin 100 mg PO BID for 5 days
- Phenazopyridine 200 mg PO TID PRN for urinary discomfort (limited to 2 days)
She was educated on:
- Completing the full course of antibiotics
- Increasing oral fluid intake
- Proper perineal hygiene (wiping front to back)
- Urinating after sexual intercourse
- Using barrier protection consistently to reduce STI risk
The patient was advised to return if symptoms did not improve within 72 hours, if fever or back pain developed, or for abnormal STI results. Follow- up was planned pending culture or test findings.
🠀 Plan
- 🠀 Diagnostics
Urine culture – Sent to confirm organism and sensitivities (esp. if symptoms persist) Urine hCG – Done to rule out pregnancy (important before giving certain meds) GC/Chlamydia NAAT – STI screening due to sexual activity
(You can skip repeating these if already done during the encounter.)
- 🠀 Medications
Antibiotic for UTI (based on local resistance patterns and likely E. coli) o Nitrofurantoin (Macrobid) 100 mg PO BID x 5 days
🠀 Avoid if suspicion of pyelonephritis or CrCl <
o Alternative: Trimethoprim-Sulfamethoxazole (Bactrim DS) 1 tab
PO BID x 3 days(if no sulfa allergy)
Phenazopyridine (Pyridium) 100 – 200 mg PO TID PRN for dysuria (max 2 days)
🠀 Warn that it turns urine orange
She reported being sexually active with inconsistent condom use. Physical exam was notable for mild suprapubic tenderness, but no CVA tenderness or abnormal pelvic findings. Urinalysis showed positive leukocyte esterase, positive nitrites, and trace blood, consistent with a lower urinary tract infection (cystitis). A pregnancy test was negative, and STI screening was ordered due to her sexual history. The patient was diagnosed with an uncomplicated UTI and prescribed Nitrofurantoin 100 mg PO BID x 5 days, along with phenazopyridine PRN for urinary discomfort. Education on proper hygiene, fluid intake, and safe sexual practices was provided. She was advised to follow up if symptoms persisted or worsened and to return for STI results if applicable.