Station 76
Sophie Walsh
Age: 4 year old female
Full Case
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.
Patient's Story (Role player’s brief)
Patient’s Story
Opening Statement: “Hi doctor, it seems like Sophie has another urine infection, and I’m really worried because this has happened a few times now, I just don’t understand why it keeps coming back.”
You are Lucy, the mother of Sophie, a 4-year-old girl who has had two confirmed urinary tract infections (UTIs) in the last six months. Today, Sophie is again complaining of passing urine more frequently and says it hurts when she pees. You’ve also noticed that her urine has a strong smell.
Each time she’s been unwell, her urine was tested, antibiotics were prescribed, and she improved. However, you’re concerned because the infections keep returning.
You’re currently teaching Sophie how to wipe herself after using the toilet, but she is still learning and doesn’t always do it properly. You wonder whether this might be contributing to the infections. Otherwise, Sophie is well, she eats and sleeps well, and her growth and development seem normal.
You’re worried about why the infections keep happening, whether they could cause long-term problems, and if there’s anything you should be doing differently. You’ve been attentive to her hygiene but wonder if you’re missing something.
You would also like to know if there’s a chance something more serious could be going on, even though Sophie appears healthy in general.
Social History: You live with Sophie and her biological father. No family history of kidney disease. No safeguarding concerns or suspicion of abuse. Sophie attends reception class at school, and there have been no concerns or complaints from school.
Pregnancy, birth, immunisation and developmental history are all normal.
Ideas: You think Sophie’s difficulty with wiping herself properly might be causing the infections.
Concerns: You’re worried about long-term damage to her kidneys or bladder.
Expectations: You want advice on preventing further UTIs, reassurance about Sophie’s health, and guidance on whether investigations or a specialist referral are needed.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about current symptoms and their onset —frequency, dysuria, haematuria, abdominal pain, fever
- Ask about how often UTI symptoms have occurred in the past
- Ask about any nausea or vomiting
- Ask about bowel habits, specifically constipation, as this can contribute to recurrent UTIs in children
- Ask about toilet habits, how often she passes urine and whether she empties her bladder fully
- Ask about fluid intake, including the use of fizzy drinks
- Ask about toilet hygiene, specifically whether the child wipes from front to back, as wiping back to front can increase the risk of urinary tract infections in girls, especially during toilet training or early independence
- Ask about home situation and who lives at home
- Ask if the child has shown any changes in behaviour, such as becoming withdrawn, fearful, irritable, or showing a loss of interest in usual activities to rule out any potential abuse.
- Ask sensitively if the parent has any concerns about possible abuse or if anything at home or school is worrying the child. For example; ” Mrs Walsh, I ask all parents this, just to be thorough and I completely understand this can be difficult to talk about, but has there ever been anything that’s made you worry about anyone possibly behaving inappropriately towards Sophie?”
- Ask about any family history of kidney or urinary tract conditions
- Ask for PBIND history—pregnancy, birth, immunisation, nutrition, and development
- Give a diagnosis of recurrent urinary tract infection (UTI)
Example of explanation to patient’s Mum
Thanks for speaking with me today, Lucy. I can hear how worried you are, and it’s completely understandable, repeated infections in a young child can be concerning.
Based on what you’ve said and Sophie’s history, it does sound like she may be having another urinary tract infection. We will need to test her urine today to check. If the dipstick suggests infection, we’ll start antibiotics straight away, using the one that worked well for her previously.
You mentioned you think it might be related to Sophie learning to wipe herself. That’s a really valid thought. Improper wiping can increase the risk of infection in young girls. Encouraging her to wipe from front to back is important, and I can send you some tips from the ERIC website to help support her with this.
I also hear that you’re worried about whether these infections could harm her kidneys or bladder long-term. That’s a very reasonable concern. Because she’s had more than one UTI in a short space of time, we will arrange an ultrasound scan of her kidneys and urinary tract to check for any underlying issues. I will also refer her to a specialist who can review the scan and decide if any further tests are needed. They might consider preventive antibiotics, but only if appropriate.
In terms of what more you can do at home: make sure she stays well hydrated, goes to the toilet regularly, wipes correctly, wears cotton underwear, and avoids bubble baths or perfumed products.
Management
Management
- Offer a face-to-face appointment to clinically assess patient and perform a urine dipstick test; send the sample for urine culture
- Explain that if today’s dipstick indicates signs of a UTI, you will start antibiotic treatment based on her previous sensitivity results
- Provide lifestyle advice to reduce the risk of recurrence such as encouraging adequate fluid intake, regular toileting and complete bladder emptying, teaching and supporting proper wiping technique (front to back)
- Advise use of cotton underwear and avoidance of synthetic fabrics. Also, advise to avoid perfumed bubble baths and other potential irritants
- Offer an ultrasound scan (USS) of the urinary tract within 6 weeks in line with NICE guidance and refer the patient to a specialist (paediatrician)
- Inform the parent that the specialist will review the scan, may request further imaging (e.g., DMSA or MCUG), and might consider prophylactic antibiotics if necessary
- Provide clear safety netting: advise to seek medical attention if symptoms worsen, if there is fever, visible blood in the urine, or further recurrence of UTI symptoms
Learning point from this station:
This station highlights the importance of recognising and managing recurrent urinary tract infections (UTIs) in children, particularly young girls who are at higher risk due to anatomy and developing hygiene habits.
Recurrent UTI in children is defined clinically as:
- Two or more episodes of upper UTI/pyelonephritis,
- One episode of upper UTI plus one or more lower UTIs, or
- Three or more episodes of lower UTIs (cystitis).
No timeframe is given over which these need to occur.
The reason there is no set timeline, unlike in adults, is that any recurrence of UTIs in children, regardless of timing, is considered potentially significant and should prompt investigation to avoid missing underlying urinary tract abnormalities or structural problems.
According to NICE guidance, all children with recurrent UTIs should be referred to a paediatric specialist for further assessment and investigations, including renal ultrasound to rule out structural abnormalities or vesicoureteric reflux.
The station also reinforces the importance of parental education on hygiene habits (e.g. wiping front to back), avoiding irritants like bubble baths, and ensuring early follow-up if symptoms recur.