Acute Pyelonephritis

Brain ENT Chest Abdomen GUT

Case: You are a GP and a 55-year-old female came in complaining of flu-like illness.

History:
- I understand you have come here because you are not feeling well. Could you please tell me more about it?
- When did it start? Did you measure your temperature? Is it up or down or constantly high? Do you have chills or
shivers?
- Septic history: Do you feel dizzy? Do you have headache? Have you noticed neck pain or stiffness? Do you have an
ear ache? Runny nose? Sore throat?
- Cough? Do you feel short of breath? Do you have chest pain?
- Hows your appetite? Do you feel nauseous? Have you vomited? Do you have abdominal pain? Diarrhea?
- Do you have back pain? How are your waterworks? Do you have burning sensation when urinating? Has the color of
your urine change? Any unpleasant smell? Do you have joint pain or rash?
- Are you generally healthy?
- SADMA? Allergy!
- Who do you live with? Is anybody else at home sick?
- Have you been traveling anywhere recently?

Physical examination
- General appearance: signs of dehydration
- Vital signs (39.7), tachycardic, rest normal
- ENT exam; neck stiffness and lymph nodes
- Chest and heart examination
- Abdomen: distention, tenderness, organomegaly, no peritonitis, kidney punch (renal angle-tenderness) 70% is
usually on the right side
- Urine dipstick (protein, nitrates and leukocytes)

Investigations
- FBE, Urea,electrolytes and creatinine, ESR/CRP, Midstream urine for culture and sensitivity, ECG, blood culture
(especially if T>38)
- USG to rule out obstruction

Management
- Jenny according to your history and PE, you have a condition called acute pyelonephritis. Have you ever heard about
it? It is a kidney infection commonly caused by E. coli. It is a bacteria which lies in the bowel and may ascend to the
kidney causing inflammation.
- Mild infection can be treated as outpatient. However, in your case, it is affecting your general condition causing high
fever with chills and rigors and fast heart rate which are signs of severe infection which means you need admission to
the hospital.
- In the hospital we will arrange blood tests and urine tests plus probably usd to exclude urinary tract obstruction. You
will receive intravenous fluids plus antibiotics to prevent dehydration (Ampicillin + Gentamycin cover E. coli and
enterococci for 2-5 days) followed by oral antiobiotics for 2 weeks
- Ampicillin 2g IV q6 + gentamycin 4-6mg/kg/day OD
- After treatment, urine microscopy and culture (24-48 hours after antibiotic) will be repeated to make sure infection is
cleared. In case infection persists, then different antibiotic is needed.