Station 76
Sophie Walsh
Age: 4 year old female
Doctor
Patient’s Data
Patient’s Name: Sophie Walsh
Age: 4-year-old female
Past Medical History:
- None recorded
Drug and Allergy History:
- Not currently on any medication
- No know drug allergy
Alerts and QOFs
- Immunisations up to date
Recent Notes/Consultation:
Seen Face to face 6 months ago by Dr Henry Okocha (Clinical practitioner role)
Presenting complaint: Mum reports frequency and dysuria in patient.
Examination: Vitals are stable. Urinalysis: Nitrites positive, Leucocytes 2+
Plan: Treat as UTI with trimethoprim. Urine Sent for culture, safety netting and worsening advice given.
Urine Culture Report (6 months ago)
Microscopy:
- White Blood Cells (WBC): 25-50 / HPF (elevated)
- Red Blood Cells (RBC): 0-5 / HPF
- Bacteria: Moderate gram-negative bacilli observed
Culture Results:
- Growth: Escherichia coli (E. coli)
- Colony Count: >100,000 CFU/mL (significant bacteriuria)
Antibiotic Sensitivity:
| Antibiotic | Sensitivity |
|---|---|
| Amoxicillin | Resistant |
| Nitrofurantoin | Sensitive |
| Cefalexin | Sensitive |
| Trimethoprim | Sensitive |
| Ciprofloxacin | Sensitive |
| Amoxicillin-Clavulanate | Resistant |
Seen Face to Face: 2 months ago by Dr Bianca Chopra (Clinical Practitioner Role)
Presenting Complaint: Mum reports frequency and dysuria in patient. 2nd episode within the last 3–4 months.
Examination: Vitals stable. Urinalysis – leucocytes 2+ and nitrates positive.
Plan: Treat with Trimethoprim as per previous sensitivity, safety netting and worsening advice given.
Follow-up: Patient’s mum (Lucy Walsh) booked urgent appointment to discuss ongoing concerns.