Please respond to discussion below using current APA edition and 2 scholarly references. Must be at least 150 words.
The patient is an 82-year-old male with a history of recurrent urinary tract infections and dementia who presents with foul-smelling urine, incontinence, and restlessness. A score of 23 or less on the Mini-Mental State Examination signifies dementia (Gluhm et al., 2013). The patient’s last MMSE score three months ago was 18, meaning there is mild cognitive impairment. Obtaining additional information about the patient’s presenting symptoms may be difficult, considering his mental state. If the patient can answer questions appropriately, the provider should ask if he is experiencing fevers, urinary frequency, urgency, suprapubic pain, difficulty urinating, and blood in the urine (Sabih & Leslie, 2023). If the patient cannot provide additional information, subjective data may be obtained from his son or staff from the long-term care facility where he lives. The provider should inquire about changes in urine output, behavior, mobility, diet, recent falls, and recent infections.
- Additional objective data
Since the patient may be unable to provide additional information about his presenting symptoms, a comprehensive physical exam should be performed. First, vital signs should be obtained and evaluated. The provider should assess for signs of severe dehydration or sepsis that require immediate attention. The patient’s mental, cognitive, mobility, and functional status must also be evaluated. A focused genitourinary exam should also be performed. Things to look for include genital inflammation or irritation, bladder distention, suprapubic tenderness, flank pain, or abnormal masses. A urine sample should be obtained, and the provider must evaluate the urine’s color, clarity, and odor.
- Differential diagnoses
Potential differential diagnoses for an elderly male patient presenting with foul-smelling urine, incontinence, and restlessness include complicated urinary tract infection, acute pyelonephritis, obstructive pyelonephritis, genitourinary abscess, bladder cancer, focal nephronia, and prostatitis (Sabih & Leslie, 2023). Elderly patients with dementia who have a urinary tract infection may present with increased confusion or agitation instead of the typical lower urinary tract symptoms (Sabih & Leslie, 2023). Based on the patient’s history and presenting symptoms, the provider should also consider that the urinary incontinence may be due to progressive dementia, recent indwelling catheter use, or post-op hip surgery complications.
- Laboratory tests
Before antibiotic treatment is initiated, a urine sample should be obtained and sent to the lab for urinalysis and culture (Sabih & Leslie, 2023). A CBC, CMP, and CRP should also be obtained to assess the hydration status and signs of infection.
- Radiological examinations
This patient would benefit from a renal ultrasound or CT scan. Renal ultrasounds are quicker and noninvasive and help identify urinary retention, genitourinary abscesses, calculi, and obstructions (Sabih & Leslie, 2023). A bladder post-void residual should also be obtained to assess for urinary retention and ineffective urinary elimination. Since the patient recently had hip surgery, he would also benefit from an X-ray or CT scan of the hip to assess for post-operative problems.
- Treatment and specific information
The treatment plan will depend on the history, physical, lab, and diagnostic tests findings. If an infection is identified, the plan will vary depending on the severity of the infection and the patient’s medical history. The treatment plan for urinary tract infections includes antibiotics and fluid resuscitation. If the patient is experiencing an uncomplicated urinary tract infection, a five-day antibiotic regimen of Nitrofurantoin, Trimethoprim-sulfamethoxazole, or Fosfomycin is typically prescribed. Amoxicillin-clavulanic acid, Cefpodoxime, or Ciprofloxacin may be used if first-line agents cannot be used (Lawati et al., 2023). If the patient is experiencing a complicated UTI, a 10-14 day antibiotic regimen is prescribed (Sabih & Leslie, 2023). Longer duration of antibiotic therapy may be needed for men with recurrent UTIs, as it may take 4-6 weeks to eliminate the infecting bacteria (Sabih & Leslie, 2023). If a urinary tract obstruction is identified, the patient may require surgery, such as ureteral stent placement or percutaneous nephrostomy (Sabih & Leslie, 2023).
- Potential complications
Potential antibiotic side effects include nausea, vomiting, diarrhea, stomach pain, and allergic reactions. Since the patient has recurrent urinary tract infections and extensive antibiotic use, he is at risk for antibiotic resistance. Antibiotic resistance puts an individual at risk for kidney injury and sepsis. Septic patients require IV antibiotics, aggressive fluid resuscitation, and vasopressors if they do not respond to fluid resuscitation (Sabih & Leslie, 2023).
- Additional laboratory tests
If the patient has an untreated or worsening UTI, he is at risk for urosepsis. Blood cultures should be obtained to rule out a systemic infection.
- Patient teaching
The patient, family members, and nursing home staff should be educated on urinary incontinence management and proper hygiene to prevent recurrent infections. Individuals with dementia are at an increased risk for urinary tract infections due to poor personal hygiene and an increase in elimination conditions (Sabih & Leslie, 2023). Education on antibiotic compliance, adequate oral hydration, and safety precautions should also be given.
- Consult
According to the patient’s son, his father has a history of recurrent urinary tract infections. A referral to a urologist should be made for further evaluation and treatment.
