The Art of Listening: A Not-So-Simple UTI

Many clinics allow the practice of ordering antibiotics for women who claim to have symptoms of a urinary tract infection. In some cases patients bring in a sample, and in some they produce the sample in the clinic in a free “Nurse Visit”. The doctor is then expected to prescribe without evaluating the patient.

The only provider on duty one Saturday this fall, I was asked to do just that. I asked the medical assistant: “Exactly what are the symptoms and is this a patient who gets UTIs all the time?”

“Doesn’t look like it, she’s only been seen once before and that was over a year ago.”

“Gotta be seen, just double book her”, I said.

The woman was in her fifties, came in as a new patient a little over a year ago. She had a history of colon cancer and was behind on her followup colonoscopy surveillance. In that one and only visit she expressed some hesitation about getting that done because she was new in town. She wanted to think about it. She did agree to getting a mammogram scheduled, and she agreed to get some basic bloodwork – but never did. From what I could tell, the mammogram was actually never done.

Her urine had a trace of leukocytes, white blood cells, and a trace of blood, both common findings even in healthy women.

“What kind of symptoms do you have?” I asked.

“I’ve got this pressure but I don’t always go very much.”

“How long has that been?”

“About three weeks now.”

“Does it burn or sting when you go?”

“Only sometimes.”

“Do you get urinary infections often?”

“I’ve only had one in my life”, was her answer.

On exam, she was a little tender over her bladder and deep to the left, but her belly was soft and I couldn’t feel anything suspicious.

I pointed out that she had hesitated about Dr. Grogan scheduling a colonoscopy. She said she had thought that was going to happen but she never heard back.

I showed her his chart entry and explained:

“Your symptoms may or may not be from an infection. I’ll start an antibiotic for you but whether a culture shows anything or not, you’re due for your colonoscopy and you may even need a CT scan if that tenderness in your belly doesn’t go away. For that reason I really suggest we get that bloodwork going, because the CT scan would require contrast. So my suggestion is, take the antibiotic, get the bloodwork and see doctor Grogan to follow up on your symptoms.”

I messaged the receptionist to make a followup appointment and we wrapped up the visit.

A prescription for an antibiotic without a visit could have had tragic consequences. I don’t believe in accepting a patient’s self diagnosis without double checking it. I also don’t believe in prescribing without taking a look at the bigger context of the most apparent presenting symptom.