Flank pain – UTI

Vignette

A 58-year-old lady attends A&E with 4 days history of right-sided flank, abdominal pain, and nausea. This is followed by rigors, general malaise, and poor oral intake.

Past Medical History

• Type 2 DM (diet controlled)

Medications

• Nil regular

Observations

• Temp: 39.1°C
• HR: 115
• BP: 95/60
• RR: 18
• Sats: 94% on air
• BM: 8.1

Question

Please discuss your approach in this patient.

Model Answer

The candidate should assess the patient in a systemic manner:

• Get full history as able.
• Repeat observations.
• Send off bloods including blood cultures, FBC, U&Es, CRP, LFTs, clotting, and VBG. May consider lipase.
• Examine the patient clinically – reveals right renal angle tenderness, not peritonitic.

Investigations

• Ask for bladder scan.
• Urine dip + MSU.
• Monitor stools.
• ECG.
• Consider USS abdomen/KUB.

Differentials Include

• Upper UTI/pyelonephritis.
• Lower UTI.
• Pancreatitis.

Treatment

• Identify clinically unwell.
• In A-E manner, manage in resus/level 1 area.
• Start empirical antibiotics for upper UTI/pyelonephritis.
• IV fluids.
• Anti-emetics.
• Escalate to senior.

Further History

• Bladder scan shows around 600 mls in bladder.
• Bedside renal USS – no obvious hydronephrosis.
• New AKI on bloods + CRP 450, lipase 6.

How would you manage this patient further?

The candidate should state they would:

• Continue to monitor closely.
• Catheterize this lady after a discussion with the patient.
• May need a CT scan to rule out infected renal stone if ongoing temperature spikes despite antibiotics/haemodynamically unstable +/- discussion with Urology.
• Patient will need daily U&Es for AKI/fluid input and output monitoring as well as blood glucose monitoring.