The EM Educator Series: UA for all – Pearls & Pitfalls in the ED setting

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. We are working on retroactively doing this for the past posts as well. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Mini-Cases:

# 1: A 24-year-old female presents with dysuria and frequency. Her VS are normal, and she otherwise feels well. She denies vaginal discharge or bleeding. You order a urinalysis, but question ordering a urine culture as well.

# 2: A 79-year-old male presents with frequent falls. He endorses generalized weakness but denies other symptoms including chest pain, abdominal pain, dyspnea, dysuria/frequency, and edema. A urinalysis sent from triage shows 4 WBCs, trace LE, and negative nitrites.

Considerations:

1. What are the components of a urinalysis and urine dipstick, and what do they mean? (color / clarity / glucose / bilirubin / ketones / spec gravity / blood / pH / protein / urobilinogen / nitrite / LE / RBC/ WBC / bacteria / squam / hyaline casts)
2. What may cause false positive and false negative results for leukocytes, nitrites, ketones, and blood?
3. What is the relationship between squamous cells and contamination?
4. Does cloudy, smelly urine = UTI?
5. Does +LE and/or WBC diagnose UTI?  What is the differential for sterile pyuria?
6. Is a positive nitrite diagnostic of UTI?
7. Is a urinary pregnancy test always reliable?
8. Who needs a urine culture?
9. When should you treat asymptomatic bacteriuria?
10. Elderly patients with recurrent falls or AMS… is a UTI responsible?
11. How does a urinary stent impact urinalysis testing and the diagnosis of UTI?
12. How do you interpret urinalysis in a catheterized patient, and how do you diagnose UTI?

Suggested Resources:

• Articles:
  • EP Monthly Part 1: The Lowly Urinalysis: How to Avoid Common Pitfalls
  • EP Monthly Part 2: Complicated UTI Part II: Understanding Special Populations
  • LITFL Urine Analysis
  • emDOCs: UTI – Pearls and Pitfalls in Urine Testing
  • ALiEM Uncomplicated Urinary Tract Infection in Older Adults: Diagnosis and Treatment (Part 1)
  • ALiEM Uncomplicated Urinary Tract Infections in Older Adults: Diagnosis and Treatment (Part 2)
  • emDOCs: Foley Catheter Patients: Common ED Presentations / Management / Pearls & Pitfalls
  • emDOCS: Pyelonephritis: It’s not always so straightforward…
• Podcast:
  • EM Cases – Episode 94 UTI Myths and Misconceptions