Febrile Child OSCE - UTI in Child

Case Overview

• Age/Sex: 9-year-old male
• Occupation: Primary school student
• Setting: Paediatric urgent clinic; parent as historian
• Chief complaint: "He’s had a fever"

Patient Script

Who I Am

I’m his mother — my son is 9 years old and in year 4 at primary school.

What Brings Me In

He’s had a fever for a couple of days and says it hurts when he pees.

My Story

My son developed a fever of about 38.5°C two days ago and has been a bit quieter than usual. Yesterday he started telling me his tummy felt uncomfortable and that it stung when he went to the toilet. He’s been asking to go more often than usual and says he needs to wee straight away when he feels it. He had a small episode of bedwetting last night which is unusual for him. He hasn’t been vomiting but didn’t want his dinner yesterday. He had a bit of a runny nose yesterday and a very mild cough but no bad chest symptoms. There was a sore throat a few weeks ago that settled on its own. He’s been going to the school swimming pool this week.

My Medical Background

• Past medical history: no previous urinary tract infections; toilet trained day and night since age 4; uncircumcised
• Medications: none regularly
• Allergies: none known
• Social: lives with parents and a younger sister; no recent travel; attends school and swimming lessons
• Family history: no known kidney disease or reflux

What I Think & Worry About

• I’m worried it might be something serious like a kidney infection or that he could be dehydrated.
• I’m worried because he’s been crying when he wees and it’s not normal for him to wet the bed.
• I wonder if the swimming or the sore throat had anything to do with this.

If You Ask Me About Other Symptoms...

• Appetite: He has eaten a little but not his usual amount in the last 24 hours.
• Vomiting/Diarrhoea: No vomiting; stools normal today but sometimes constipated.
• Respiratory: Mild runny nose and cough started yesterday; no shortness of breath.
• Pain: He localizes the discomfort to his lower tummy and says it stings when peeing; no flank pain reported.
• Urine: He says it sometimes looks a little darker than normal and he complained of blood on one wipe last night (I didn’t see it clearly).
• Genital issues: No trauma; no previous problems; he is uncircumcised and I sometimes see a bit of redness around the tip which I thought was from wiping.
• Behaviour: He’s more tired than usual but can be comforted and is drinking small amounts.

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Clinical Summary

Examination

• General: alert, mildly ill-appearing child
• Temperature: 38.6 °C
• Heart rate: 110 bpm
• Respiratory rate: 20 /min
• Blood pressure: 102/64 mmHg
• Oxygen saturation: 99% on room air
• Abdomen: soft, suprapubic tenderness on palpation, no guarding or rebound
• Costovertebral angle: no loin tenderness bilaterally
• Genital exam: uncircumcised male; mild erythema at meatus; no obvious discharge; no scrotal swelling
• Neurological: normal for age

Investigations

• Urine (clean-catch midstream) — Dipstick: Leukocyte esterase: +, Nitrite: + (Test interpretation: supports bacterial UTI)
• Urine microscopy: WBC 50–70 /hpf, RBC 8–12 /hpf, moderate gram-negative rods seen
• Urine culture: Escherichia coli >100,000 CFU/mL (sensitivity: susceptible to cefalexin and trimethoprim-sulfamethoxazole)
• CBC: WBC 13.2 x10^9/L (neutrophils 9.8 x10^9/L) (mild leukocytosis)
• CRP: 25 mg/L (mildly elevated)
• Pregnancy test: not applicable
• Note: No imaging done at initial visit

Diagnosis

• Primary diagnosis: Acute lower urinary tract infection (cystitis) due to Escherichia coli

  • Supporting evidence: 2-day history of fever, dysuria and frequency, suprapubic tenderness, positive leukocyte esterase and nitrites on dipstick, microscopy with pyuria and bacteriuria, and urine culture with >100,000 CFU/mL E. coli.

• Differentials and reasoning:

  • Acute pyelonephritis: less likely — fever present but no flank/CVA tenderness, clinical picture consistent with lower tract on exam and mild inflammatory markers; must monitor for progression.
  • Gastroenteritis: less likely — no vomiting or diarrhoea, localizing urinary symptoms present.
  • Urethritis (non-bacterial causes/STI): unlikely in a 9-year-old with no sexual history and culture positive for E. coli.
  • Constipation-related urinary symptoms: may contribute to urinary frequency/bedwetting, but does not explain positive urine culture and pyuria.
  • Viral cystitis or transient haematuria after exercise: less likely given positive culture.

Management

• Acute

  • Obtain urine sample for microscopy and culture before starting antibiotics (clean-catch midstream; if unobtainable, consider catheter sample).
  • Start empiric oral antibiotic while awaiting culture sensitivities: e.g., cefalexin (dose per local paediatric guidance, typically 25–50 mg/kg/day divided q6–8h) for 7–10 days for boys; adjust based on culture sensitivities.
  • Analgesia and antipyretic: paracetamol as needed; ensure adequate oral fluids.
  • Safety-netting: advise return/urgent review if persistent fever despite 48 hours of antibiotics, vomiting, poor oral intake, flank pain, lethargy, or signs of sepsis.

• Follow-up and further evaluation

  • Review urine culture results and adjust antibiotics if required.
  • Arrange paediatric urology or nephrology input and renal ultrasound after the acute infection in a male child with a first UTI to exclude anatomical abnormality or obstruction (boys have higher pre-test probability for underlying anomaly).
  • Consider assessment and management of constipation if present, and discuss genital hygiene; discuss circumcision as a longer-term risk-reduction consideration with specialists/parents if recurrent UTIs occur.

Key Learning Points

• Always obtain an appropriately collected urine sample for dipstick, microscopy and culture before starting antibiotics when feasible; dipstick leukocyte esterase and nitrite together increase the likelihood of bacterial UTI.

• UTI in boys is less common than in girls and should prompt consideration of underlying urinary tract abnormality — early imaging and specialist referral are more likely to be indicated in males, especially after a first febrile UTI.

• Differentiate lower UTI/cystitis from pyelonephritis by history and exam (fever with flank pain, systemic toxicity, or significant CRP/WBC elevation suggests upper tract involvement); re-evaluate promptly if clinical course worsens.