Objectives:

What is dysuria? What are the causes of it?

How do you interpret a urinalysis result? How do you correlate it with the
patients symptoms?
What is cotrimoxazole? What does it treat and its side effects?
How can a positive renal punch be interpreted?
What further diagnostic tests are needed to evaluate the condition of the
patient?
What are the probable diagnoses based on the results of the patients
laboratory exams?
The patient, 21 y/o had dysuria for 3 days prior to check up. Urinalysis results
came back with notable elevations in bacteria, RBC (Normal 0-2), and WBC
(<5). The urine specific gravity is 1.210 which is unusually high (1.030 is the
upper limit in reagent strips). This may be a mechanical error or can be based
on refractometer computations.
Dysuria may be simply defined as painful urination. It is a pain or burning
with urination, usually felt in the tube that carries urine out of your bladder
(urethra) or the area surrounding your genitals (perineum).It can be caused
by bladder stones, chlamydia, cystitis, UTI, STD, urethritis, prostatitis, and
certain drugs (usually for cancer treatment).
Cotrimoxazole was prescribed. However, persistent high fever occurred after
taking the medicine for 7 days. Then the patient was admitted and
underwent to several tests namely renal punch test (positive) and urine
culture using foley catheter (positive for E.coli & N. gonorrhea). His social
history was reviewed and turned out that hes a social drinker, non-smoker
and frequent in brothels.
The patient for this case might have several probable illnesses that need to
be confirmed. Those are UTI, STI, oxalate calculi, urethritis, gonococcal
urethritis and pyelonephritis. With the admitting diagnosis of dysuria and
high grade fever, all these are possible.
Urinary tract infection as observed in the routine urinalysis. A possible
contamination is rejected for the number of WBC is also increased. The
administration of the cotrimoxazole is supposed to treat the urinary tract
infection. But the persistent high grade fever suggest that it did no cured the
patient. Cotrimoxazole is a broad spectrum of antibiotic which can be used to
treat bacterial infections. It is made up of two drugs - trimethoprim and
sulphamethoxazole (TMP-SMX) is a ratio of 1:5. Some bacterial infections,
such as urinary tract infections, have been found to respond just as well to
trimethoprim alone. It is prescribed for patients with pneumonia (children),
typhoid, dysentery, UTI and pneumocystis pneumonia.
Further tests was done like the kidney punch or the Lloyds sign. This can be
an indicator for infection or pyelonephritis or inflammation. It is also helpful

for the diagnosis of kidney stones. Further laboratory test is required

specifically the complete blood count to check if theres and elevation in WBC
in the blood which is an indicator of infection.
The patient also tested positive for urine culture to E. coli and N. gonorrhea.
Catheterized specimen was used so the risk of contamination is much less
compared to midstream clean catch. This is an indication that the patient
probably has gonoccocal urethritis and UTI as well.

Other tests to further evaluate the patients condition might include blood
tests:
complete blood count to check if theres an elevation in patients WBC in the
circulation;
vitamin D3, parathyroid activity and serum calcium determination in parallel
to the presence of calcium oxalate in the urinalysis done to the patient which
may indicate oxalate calculi or stone in the kidney
We should also check if the patient has a discharge in the penile area and is
sexually active (evident in his social history):
should perform urethral smear and culture to confirm gonoccocal urethritis
The pyuria of the patient should be further evaluated through quantitative
urine culture:
if >103 CFU per ml. single organism, it is UTI, otherwise, it could be neoplasm,
prostatitis, tuberculosis or epididymitis.

References:
http://www.mayoclinic.com/health/painful-urination/MY00734
http://www.wisegeek.com/what-is-lloyds-sign.htm
http://www.who.int/chd/publications/newslet/dialog/5/cotrimox.htm
http://www.aafp.org/afp/2002/0415/p1589.html
Widmanns Clinical Interpretation of Laboratory TestsRonald A. Sacher and Richard
A. McPherson (2010)
Urinalysis and Body FluidsSusan King Strasinger and Marjorie Schaub Di Lorenzo
(2008)
Robbins and Cotran Pathologic Basis of DiseaseVinay Kumar, et. al.

Prepared by: Gerald John Paz