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December 2015: Lower Abdomen

A 49-year-old cook reported to the medic with a complaint of painful urination for the past two days and new onset of right sided flank pain with nausea for the last 8 hours. Her pain is constant and progressively worsening and she denies any episodes of vomiting.

On review of systems she denies chest pain, shortness of breath, dizziness, headache, vision changes, or rashes. She is on day 16/21 of her hitch.

  • Past History: Diabetes (NIDDM), hypertension
  • Past Surgical History: C-Section (x2), breast augmentation, endoscopic sinus surgery (FESS)
  • Current Medications: Metformin (Glucophage) 1,000 mg bid, saxagliptin (Onglyza) 2.5 mg per day, losartan 50 mg per day
  • Immunization Status: Tetanus and Influenza are up to date
  • Social History: Social drinker, smokes 1 packs per day for 20+ years
  • Family History: Father with diabetes, mother with high blood pressure and history of stroke (58 y/o)

Vitals

  • Temp: 102.7
  • Pulse: 105
  • Respirations: 16
  • Blood pressure: 162/102
  • Pulse Ox: 97% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress, sick appearing female vomited as she entered clinic
  • HEENT: AT/NC, eyes anicteric, TMs clear, nose clear, nares clear
  • OP/OC: tonsils appear erythematous with purulent discharge, mucus membranes are moist, postnasal drip appreciated in posterior pharynx
  • Cardio: Regular rhythm tachycardic, 2/6 systolic ejection murmur
  • Lung: Clear to auscultation bilaterally
  • Abdomen: Soft, super-pubic tenderness, non-distended, no guarding or rebound, normal bowel sounds, no organomegaly
  • Back: Right CVA tenderness
  • Extremities: No clubbing, cyanosis or edema

Lab Work

    Urine Analysis

  • Color – straw with a pink tinge
  • Clarity – cloudy
  • Specific gravity – 1.030
  • pH- 6.5
  • Glucose – 4+
  • Bilirubin – negative
  • Blood – 2+
  • Urobilinogen – 0.2 EU
  • Protein – 1+
  • Ketones – 10+
  • Nitrite – positive
  • Leukocyte esterase – 2+

How would you approach this patient?

Differential Diagnosis

  • Nephrolithiasis (Kidney Stone)
  • Pyelonephritis
  • Cystitis
  • Vaginitis
  • Pelvic inflammatory disease (PID)

Diagnosis: Pyelonephritis

Treatment:

  • Promethazine (Phenergan) 25mg IM or ondansetron (Zofran) 4 mg IM for nausea
  • Acetaminophen (Tylenol) 1 gram every 6 hrs for fever
  • Ceftriaxone (Rocephin) 1 gram every 24 hrs (IV or IM) for infection
  • Once patient can tolerate oral medication start levofloxacin (Levaquin) 750 mg daily for 14 days for infection

Discussion:

This will be a complex case that will require care for multiple conditions. As the patient is currently be treated for hypertension and type II diabetes it is necessary to provide support for the patient’s existing conditions until the acute infection improves and resolves. Symptomatic control of the fever and nausea are important to allow the patient to begin oral medications. Until such time, medications and hydration will need to be delivered parenterally.

Pyelonephritis is caused predominantly by infection with E. coli which makes it susceptible to an array of medications. Alternative medications for this patient include ciprofloxacin (400mg IV every 12 hours or 500 mg bid orally) or trimethoprim/sulfamethoxazole (Bactrim DS; 160/800 bid). Urine cultures can be used to confirm the exact organism and sensitivities to medications, however laboratory data will not be available for several days. The patient will need to be monitored clinically for a response to the treatment.

Due to the complexity of this patient’s condition, it is necessary to stabilize the patient prior to transport to a higher level of care where other complications such as kidney stones, obstruction or kidney damage may be ruled out.

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