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Abstract: A 54-year-old aunt Lu came to our hospital for treatment of frequent, urgent and painful urination with hematuria in the naked eye for 1 day.
Basic information】Female, 54 years old
Type of disease】Urinary tract infection
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Time of consultation】August 2019
Treatment plan】Oral medication (compound cefaclor tablets, levofloxacin hydrochloride tablets, sodium bicarbonate tablets)
Treatment period】Medication for 1 week, regular follow-up
Treatment effect] The disease was cured and all indexes returned to normal
I. Initial consultation
The patient, a 54-year-old female, identified herself as Lu, and reported that she suddenly developed symptoms of urinary frequency, urgency, and painful urination about 1 day ago, with a feeling of incomplete urination, accompanied by flesh-eye hematuria, as well as a slight feeling of difficulty in urination, accompanied by lower abdominal distension and discomfort. He came to our hospital for a definite diagnosis. He had a previous history of hypertension grade 3 and cardiac arrhythmia. On examination, I found that the patient had a flat abdomen, no abdominal wall varices, soft abdominal muscles, pressure pain in the suprapubic bladder area, no rebound pain in the abdomen, no masses were palpated in the whole abdomen, drum sounds on percussion in the abdomen, and no percussion pain in the liver, spleen, and both kidney areas. There was no redness or swelling of the urethral orifice and no discharge. The urine routine examination showed that the quantification of erythrocytes and leukocytes was significantly higher, and the bacterial count and mucus filament were also much higher than the normal index.
Second, the treatment process
After identifying the patient’s disease, I told the patient that his condition was relatively mild because he did not have systemic symptoms such as fever, chills and vomiting, and that he could be cured by oral medication for one week without hospitalization. After obtaining the patient’s consent, I actively carried out the treatment. After determining that the patient had no cephalosporin allergy, I prescribed compound cefaclor tablets and levofloxacin hydrochloride tablets for anti-inflammation and sterilization, and gave sodium bicarbonate tablets to alkalize the urine to avoid the formation of blood clots in the urine and relieve the symptoms. The patient was also instructed to go home to apply hot compresses to the abdomen to relieve the symptoms of lower abdominal distension and pain. 1 week later, he returned to the hospital for a review, and if there was any discomfort, he sought medical attention in time.
III. Treatment effect
Before the patient came to our hospital for treatment, there were symptoms such as frequent urination, urgent urination, painful urination with flesh-eye hematuria. After 1 week of treatment with the above-mentioned drugs such as compound cefaclor tablets and levofloxacin hydrochloride tablets, the patient reported that he no longer had the above-mentioned symptoms when he came back to the hospital for a follow-up examination. I checked the patient and found that the pressure pain in the suprapubic bladder area disappeared and returned to normal. Routine urine examination revealed that the red blood cell quantification, white blood cell quantification, bacterial count and mucus filament index also returned to normal, which confirmed that the patient’s condition was cured.
IV. Precautions
I am very happy for the patient’s recovery, but in order to prevent the patient’s re-emergence of urinary tract infection symptoms, we need to remind the patient to pay attention to the following points.
1, the patient in the daily diet need to pay attention to drink more water, more urination, less holding urine, conducive to the bladder and urethra bacteria out of the body, to reduce the possibility of urinary tract infection.
2, patients need to pay attention to the hygiene of the perineum clean, to reduce the number of bacteria reproduction here, and try to avoid tub baths, so as to avoid retrograde infection of bacteria bladder, or even pelvic;.
3, if the patient has a sexual life, also need to pay attention to sexual hygiene, to help prevent the recurrence of the disease.
V. Personal insight
Urinary tract infections are commonly caused by bacterial infections that can cause patients to develop diseases such as inflammatory bladder disease and pyelonephritis. The patient in this case is suffering from inflammation of the bladder, which manifests as frequent, urgent, and painful urination, accompanied by blood in the eyes and distension and pain in the lower abdomen. For patients with relatively mild symptoms, hospitalization is usually required to avoid increasing the psychological burden and treatment costs. However, for patients with a combination of systemic symptoms such as fever, chills, nausea and vomiting, hospitalization is required to fully cure the infection. Therefore, different treatment plans need to be given for different degrees of symptoms.