History of Present Illness:

Carmen Cruz, a 24-year-old Married Female, Nurse, came in for consultation complaining of urinary
frequency, back pain, and fever.

One week prior to consultation, the patient started to experience urinary frequency, occasionally
associated with dysuria. 3 days prior to consultation, patient is still having urinary frequency but the
patient now suffers from flank pain. The patient described the pain to be worse on the left side and was
increasing in intensity; she took Tylenol but this offered her no relief. The night prior to consultation, the
patient still experiences urinary frequency and flank pain, and felt feverish and had chills but her
temperature was not recorded. Few hours prior to consultation, the patient with her previous
complaints, felt nauseated and vomited twice.

The persistence of the patient’s condition prompted her to seek for medical care; hence, this
consultation.

Past Medical History

 The patient was not diagnosed with any illnesses in the past and has not been on any
medications
 She has no history of surgeries
 She is allergic to betadine

OB and Gynecologic History:

 She had her menarche when she was 14 years old

 Her menstruation has always been irregular, and has 7 days duration. She usually experiences
cramping on the first day
 She has never been pregnant

Review of systems:

 General: The patient has pain limited only to her back

 Genitourinary:
 She experiences urinary frequency and urgency
 She experiences occasional dysuria
 She does not experience nocturia, nor notices any gross hematuria on her urine
 She does not have any abnormal discharges

Physical Examinations:

 Vital signs:
 BP: 92/52 mmHg
 HR: 108 beats per minute
 RR: 20 breaths per minute
 Temp: 39 degrees Celsius
 Tachycardic
  Height: 5’11
 Weight: 106 lbs
 Palpation on the back, lower left: reveals moderate tenderness over the kidneys
 Palpation on the back, lower right: no tenderness
 Percussion of the back (kidney punch was performed on both sides): Moderate tenderness over
the kidney on the left side and no tenderness

Subjective:

 Urinary frequency that started 1 week ago

 Back pain for the last 3 days
 Urinary frequency sometimes with dysuria
 CVA tenderness on the lower left side of the back
 No diet restrictions
 Does not use illicit drugs
 Gyne history: Had her period at 14, has always been irregular, and has 7 days duration. She
usually experiences cramping on the first day

Objective:

 Vital signs:
 BP: 92/52 mmHg
 HR: 108 beats per minute
 RR: 20 breaths per minute
 Temp: 39 degrees Celsius
 Tachycardic
 Height: 5’11
 Weight: 106 lbs
 Percussion of the back (kidney punch was performed on both sides): Moderate tenderness over
the kidney on the left side and no tenderness
 Speculum: Normal vaginal wall, no cervical discharge
 Dipstick test:
 2+ leukocyte esterase
 Positive nitrite
 (-) glucose
 (-) ketone
 (-) bilirubin
 (-) blood
 Urine Gram Stain
 Numerous gram (-) rods
 Multiple WBC
 Elevated RBC
 Occasional epithelial cells
 Urine culture and sensitivity
 Clean catch urine specimen produced 4+ growth of a Gram-negative rod, subsequently
identified as E. coli.
 4+ = >100,000 CFU/cc

3+ = 10,000-100,000 CFU/cc

2+ = 1,000-10,000 CFU/cc

1+ = <1,000 CFU/cc

 Antibiotic sensitivities of the organism grown from a clean catch urine specimen are as
follows:

Amoxicillin Resistant
Amoxicillin/Clavulanate Sensitive
Cefazolin Sensitive
Cephalothin Sensitive
Ciprofloxacin Sensitive
Gentamycin Sensitive
Nitrofurantoin Sensitive
Piperacillin Sensitive
Sulfamethoxazole Resistant
Tetracycline Resistant
Trimethoprim/Sulfamethoxazole Sensitive

Assessment: Give Ciprofloxacin 500mg bid for 7 days

Plan:

 Follow-up check-up 3 days after

 Follow-up laboratory gram stain

Diagnosis:

ACUTE UNCOMPLICATED PYELONEPHRITIS

 Definition: AUP is a bacterial infection causing inflammation of the kidneys. It occurs as a
complication of the ascending UTI which spreads from the bladder to the kidneys and collecting
systems
 Healthy women without anatomic/functional urological abnormalities
 Common signs and symptoms:
 Fever (38 deg Celsius), chills, flank pain, CVA tenderness, nausea and vomiting, with or
without signs of lower UTI
 Lab findings: Urinalysis - Pyuria (≥5 WBC/ HPF), Culture - Bacteriuria (≥ 10,000 CFU/mL)
 Differential diagnosis
Acute uncomplicated cystitis
Nephrolithiasis -

 Pre-treatment:
 Urinalysis
 Gram stain
 Urine culture and sensitivity – blood C/S not recommended, unless there is a sign of
sepsis. Biomarkers not recommended, not predicting values
 Admission
 Inability to maintain oral hydration or take medication
 Concern about compliance
 Possible complicating conditions
 Severe illness – high fever, severe pain, increased debility, sepsis
 Hospital
 Ceftriaxone
 Fluoroquinolones
 Aminoglycosides
 Out patient
 Quinolones
 Initial single IV/IM of ceftriaxone or aminoglycosides followed by oral antibiotics
 Alternatives
 Enterococcal infections – ampicillin + aminoglycoside
 MDRO – Carbapenems and Piperacillin – Tazobactam
 DOT
 14 days
 7-10 days (selected fluoroquinolones)
 Imaging (not recommended for routine use)
 History of urolithiasis, urine pH ≥ 7, renal insufficiency
 Remains febrile with 72 hrs of treatment
 Symptoms recur to nephrolithiasis, UT obstruction, renal perinephric abscess
 Abnormalities
 Follow-up lab test
 Symptoms do not improve, recure after treatment – urine culture and sensitivity test