BIODATA

Child’s name: Tusasire Joan

Child’s age: 4 years
Date of birth: 03/05/2020
Sex: Female
Address: Kitagata
Nationality: Ugandan
Tribe: Muyankole
Level of education: Top class
Name of informant and relation to the patient: Akampurira Mercy, The mother.
Date of admission: 15/02/2024
Date of clerkship: 15/02/2024
PRESENTING COMPLAINTS
1. Fever since 2 days
2. Abdominal pain since 2 days
3. Increased frequency of urine since 1 day
HISTORY OF PRESENTING COMPLAINTS
A 4-year-old girl was brought to the pediatric outpatient department of KIUTH by her mother
with the history of fever, abdominal pain and increased frequency of the micturition. Mother had
noticed the fever since 2 days of moderate to high degree, no associated chills and rigors. Used
to be relieved temporarily by paracetamol. Mother also revealed that her daughter is complaining
of the pain in the abdomen. It was diffuse more so in the lower abdomen. She also told her
daughter is passing the urine very frequently. Amount of the urine used to be small. She was
crying while passing the urine. Mother had also noticed that her daughter had nausea. However
mother reported no history of hematuria, vaginal discharge.
REVIEW OF OTHER SYSTEMS
Respiratory system; Mother reported no history of chest pain, dyspnea, fast breathing, cyanosis,
cough, hemoptysis.
CVS; The mother reported no history of palpitations, fatigue, cyanosis, sweating, edema.
Integumentary system; She reports a history of rashes, but no skin bruises, pruritus, hyper or
hypo pigmentation, lumps or bumps.
Ear, Nose, throat; There was no history of ear discharge, bleeding, ear pain, scratching of the
pinna, use of a hearing aid, nasal discharge, bleeding or itching, throat pain, hoarse voice and
anterior neck swelling.
Musculoskeletal system: Mother reports no history of joint pain, joint swelling, joint stiffness,
muscle weakness, bone pain.
CNS: There was no history of headache, loss of consciousness, dizziness, vertigo, convulsions,
or tremors.
PAST MEDICAL HISTORY
The mother reports this her first admission in the hospital. She reports reported no history of
chronic illnesses like diabetes mellitus, hypertension, sickle cell disease. No known allergies to
penicillins.
PAST SURGICAL HISTORY
She reported no history of blood transfusions. She additionally reported no history of fractures,
head injuries, burns, dislocations and no history of any surgical procedures performed.
BIRTH HISTORY
Prenatal history: Mother is a 28 year old gravida 3 had her first child conceived naturally; she
has two additional children, pregnancy was planned. The mother made four visits to Kitagata
health center IV for independent prenatal care. Her first appointment was at 24 weeks, during
which she underwent tests for syphilis, HIV, and malaria which were all negative. She
additionally reported she received folic acid, iron sulphate, fansidar, and tetanus toxoid vaccine
were administered to her. She claims to have taken some herbal medicine during her pregnancy,
to have slept beneath a mosquito net the entire time, and to have avoided radiation exposure such
as x-rays.
Natal history: With the assistance of a midwife, the mother gave birth at Kitagata health centre
IV at 38 weeks via spontaneous vaginal delivery. The newborn, who weighed 3.4 kg, wailed
outright. The mother doesn't know the Apgar score. The woman's membranes burst during birth,
she spent a few hours in labour, and no medication was administered to hasten or halt labour.
Minimal bleeding occurred during delivery, there was no need for an episiotomy, and the cord
was delivered via carefully managed cord traction without any complications.
Postnatal history: After birth, the infant's health was fine; there was no fever, breathing
difficulties, yellowish or bluish skin discoloration of the mucous membranes, or cord
haemorrhage. Breastfeeding was started as soon as the baby was delivered, and the hospital stay
lasted for 24 hours. The infant received tetracycline eye ointment, vitamin K, polio 0 and the
BCG vaccine. No further treatments or medications were administered.
IMMUNISATION HISTORY
The mother reported that her daughter was fully immunized which was proved by the
immunization she carried along with her.
HISTORY OF NUTRITION
Up until six months, the mother claims to have breastfed the child entirely. At least ten times a
day, on demand, she breastfed her child. Beginning in the seventh month, additional food was
offered, including crushed almonds, mashed Irish potatoes, soy porridge, and drinking water that
the mother had made herself. After alternate feeds were introduced, the child's breastfeeding
continued until the age of nine months.
GROWTH AND DEVELOPMENTAL MILESTONES
Gross motor skills: according to the mother, the child began sitting with assistance at 4 months,
standing without assistance at 5 months, crawling at 6 months, pulling himself up to stand at 8
months, and walking at 1 year and 6 months.
Fine motor and vision: around four months old, he started reaching for things nearby.
Speech, language and hearing: At two months, she started grinning at faces and voices. The
child can now speak in complete sentences. The child currently attends no school and gets along
nicely with other kids. His mother adds that he is quite active.
FAMILY AND SOCIO-ECONOMIC HISTORY
Out of her three children, this is the first one. The other children are well and free of any long-
term illnesses. The father owns his own firm. The mother states that she does not know of any
family members who have sickle cell disease, but she does know that her grandfather's mother
had a history of hypertension. Mother and father do not consume drink or smoke. Every
youngster sleeps beneath a mosquito net. The family cooks their drinking water, which is kept in
a clean jerry can, and they reside in a permanent home with a latrine.
SUMMARY
A 4-year-old toddler girl was brought to the pediatric outpatient department of KIUTH by her
mother with the history of fever for one day, abdominal pain and increased frequency of the
micturition for two days. However the mother reported no history of hematuria, vaginal
discharge. She reported pain on urination by her daughter.
GENERAL EXAMINATION
On examination, child was moderately built and nourished. She was looking sick. Signs of
moderate dehydration were present. There was no pallor, no edema, no clubbing and no
lymphadenopathy.
VITALS
Temperature; 39.0 degrees Celsius
Pulse rate; 126 beats/pm
Respiratory rate; 22breath/pm
SPO2; 96%
ANTHROPOMETRY
The weight was 15.0kgs
Height 100 cm
MAUC-15.8 cm
SYSTEMIC EXAMINATION
1. Examining the central nervous system
Upon examination, the youngster appears to be cognizant and awake, with good time, place, and
person orientation. The child's Glasgow coma scale was 15/15, and she is not wasted or
dysmorphic. The child can flex his or her neck without complaining. The eyes shine with a torch
light, the pupils constrict.
2. CVS examination
Upon examination, the chest showed normal symmetry, no surgical scars, no malformations in
the chest, and a normative pericardium. With no femoral-radial delay and a regular, robust, full
volume pulse rate of 110 bpm, there was no radial-radial synronicity. No edoema, Osler nodes,
splinter bleeding, or finger clubbing was present. There were no heaves or thrills upon palpation.
Upon auscultation, there were no additional noises or murmurs, and the apex heart pulse was
detected in the left 5th intercostal space midclavicular line.
3. RESPIRATIONAL ASSESSMENT
Upon examination, the chest wall appears to be in normal symmetry and moves in tandem with
breathing. There are no visible masses, no clear respiratory discomfort, no noticeable treatment
or surgical scars, nasal flaring, and no intercostal or subcostal recessions. With a typical
respiratory rate of 25 bpm and a SPO2 of 96%, the breathing was regular.
Upon probing, the trachea was found in the centre, there were no discernible masses, and the
chest expanded normally and moved symmetrically. Every lung region had typical vocal and
tactile fremitus, and every lung region reacted to percussion.
Auscultation revealed bilateral equal air input and bronchio-vesicular breath sounds. There were
no other noises audible, including wheezes, stridor, or even crepitation.
IMPRESSION
Urinary tract infection
DIFFERENTIAL DIAGNOSIS
1. Pyelonephritis in view of abdominal pain
2. Vesicourethral reflux in view of fever
3. Urethritis in view of painful urination
INVESTIGATIONS DONE
1. Complete blood count
2. Urinalysis
3. Urine culture
PLAN
1. Admit to pediatric ward
2. Supportive- Administer IV paracetamol 15mg/kg per dose to reduce fever
3. Initiate antibiotic therapy- Amoxiclav 20-40mg/kg divided in three doses
4. Educate the parents on hygiene
5. Monitor the vitals
5. Give antibiotic prophylaxis after recovery
FOLLOW-UP
Improvement was seen as fever stopped, abdominal pain resolved and child no longer
complained of burning sensation on urination.
CASE DISCUSSION
Urinary tract infections (UTIs) imply invasion of urinary tract by pathogens, which may
involve the upper or lower tract depending on the infection in the kidney, or bladder and urethra.
Urinary tract infection constitute a common cause of morbidity in association with abnormalities
of the urinary tract, contribute to long term complications, including hypertension and chronic
renal failure. Prompt detection and treatment of UTI and complicating factors are of utmost
importance.
Epidemiology
The incidence of UTI in the term neonate is approximately 1% and in the preterm 3%, both with
male preponderance (male to female ratio of 5:1) during infancy. Obstructive lesions may be
found in 10% of boys investigated for UTI and 30–40% patients show vesicoureteric reflux
(VUR). The occurrence of UTI below 2 years of age, delay in starting treatment and presence of
VUR or obstruction are the chief risk factors associated with renal scarring.
PATHOGENESIS AND PATHOLOGY
The pathogenesis of UTI depends on a complex interaction between bacterial and host-factors.
The majority of UTIs are initiated by bacteria that ascend the urethra and adhere to the mucosal
lining of the bladder; a hematogenous source that seeds the urinary tract is much less common
but is also possible.
The pathogenesis of UTI is based in part on the presence of bacterial pili or fimbriae on the
bacterial surface. There are two types of fimbriae, type I and type II. Type I fimbriae are found
on most strains of E. coli. Because attachment to target cells can be blocked by D-mannose,
these fimbriae are referred to as mannose sensitive.
They have no role in pyelonephritis. The attachment of type II fimbriae is not inhibited by
mannose, and these are known as mannose resistant. These fimbriae expressed by only certain
strains of E. coli. The receptor for type II fimbriae is a glycosphingolipid that is present on both
the uroepithelial cell membrane and red blood cells. Because these fimbriae can agglutinate by
erythrocytes, they are known as P. fimbriae. Bacteria P. fimbriae are more likely to cause
pyelonephritis.
RISK FACTORS FOR URINARY TRACT INFECTION
• Premature infants
• Immunodeficiency disease
• Systemic disease
• Urinary tract abnormalities
• Renal calculi
• Neurogenic bladder
• Voiding dysfunction
• Chronic severe constipation
• Family history of UTI
• Girl less than 5 years with history of UTI
CLINICAL FEATURES
Dribbling, prolonged voiding, straining, crying during micturition and poor urinary stream
indicate an abnormality of the distal urinary tract. Diurnal incontinence, urgency, frequency and
squatting suggest voiding dysfunction. Dysuria, frequent voiding and hypogastric pain suggest
cystitis.
TREATMENT
For febrile UTI the length of treatment should be 7–14 days. In an otherwise healthy child with
suspected a febrile acute cystitis and without a history of recurrent UTI, a shorter course may be
sufficient.
Oral and parenteral antibiotics are equally efficacious treatment for a UTI: The latter is indicated
if the patient is either toxic or vomiting or if there are no oral options available.