DrUSMLE

Explanations of 861 to 864 Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the “gold-standard” but is not always technically feasible, especially in an out- patient office setting. A midstream, clean catch specimen would be acceptable in an older, toilet-trained child. “Bagged” specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly, obtaining a sample from a diaper or potty would be unacceptable. Urinalysis includes dipstick method and microscopic examination. Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/high-power field) or bacteria is also predictive of infection. RBCs are often present in a UTI.The patient is vomiting and dehydrated; this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S.saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 3–5 years and in a boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular, vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recom- mended. For more questions join @drusmle

862. Her urinalysis shows a urine specific gravity of 1.030, trace blood, and protein. Nitrite and leukocyte esterase are both positive. Microscopic examination of unspun urine shows >100 white blood cells (WBCs) and 0–5 red blood cells (RBCs) per high-power field, as well as many bacteria. A urine culture is sent. Which of the following is the most appropriate management plan?

An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 5–10% dehydrated.

Questions from 861 to 864 are linked

860. Explanation A) (A) Ciprofloxacin is the drug of choice in a dose of 500 mg bid for 1–3 days because most cases of travelers’ diarrhea are from E. coli. This patient’s symptoms are moderate to severe and warrant antibiotic treatment which will decrease the frequency of bowel movements and duration of illness. Erythromycin and tetracycline are effective for Vibrio which is an uncommon cause of travelers’ diarrhea. Metronidazole is used for Clostridium difficile enteritis For more questions join @drusmle