Flank pain

Question 1

You are the IMT 1 on the acute medical take. You have been asked to see a 27 year old female patient admitted with a 1 day history of severe right sided flank pain and vomiting. She has recently been treated for a urinary tract infection by her GP.

She has no known past medical history and does not currently take any medications.

Her observations on arrival are as follows:

Temp 38.2, RR 20, sats 98% on air, HR 116, BP 94/60

TLDR: 27 F, a/w 1/7 Hx severe R flank pain, recent Rx for UTI, no PMHx, no DHx

How would you initially assess and manage this pt?

Answer 1

ABCDE approach

A
- Ensure airway patency

B
- Monitor SpO2, monitor RR
- Give O2 if SpO2 < 94%

C
- Monitor HR, BP
- 12-lead ECG & attach continuous 3 lead EG monitor
- Establish IV access & take bloods
- VBG
- Fluid status - JVP, CRT (peripheral, central), mucosal membranes
- sBP < 100 > give 500 mL bolus
- Consider catheterisation to monitor UO
- Check allergies and give broad-spectrum IV ABx

D
- Temperature, BM
- AVPU/GCS
- Focused neuro exam

E
- Thorough abdominal exam - flank pain, RUQ pain / epigastric, peritonism
- Assess limbs for infection

Question 2

What would be your differential diagnosis for this patient?

Answer 2

The patient appears to be septic.

1. Pyelonephritis
2. Acute cholecystitis
3. Ruptured Ectopic Pregnancy
4. Gastroenteritis
5. DKA
6. Bowel obstruction
7. Community Acquired Pneumia
8. Acute Pancreatitis
9. Acute hepatitis

Question 3

What would be your initial investigations and management plan?

Answer 3

Bedside
- Monitor SpO2, HR and BP
- Give high flow O2 and IV fluids
- 12-lead EG
- Continuous 3-lead ECG
- VBG for lactate and acid base status
- Pregnancy test

Bloods
- FBC, CRP, U&E (renal function), LFTs, Bone profile, amylase
- Coagulation screen
- Blood cultures, urine dip, urine MC&S

Imaging
- Abdominal ultrasound (liver, gallbladder stones, pancreatitis, kidneys, ruptured eptopic pregnancy)
- Erect CXR (pneumoperitoneum)
- If concerned about surgical pathology > CT abdomen & pelvis

Management
My initial management would be through A-E assessment. Since this patient appears to be septic, I would start with sepsis management - Blood cultures, lactate and UO & Oxygen, antibiotics (focused on pyelonephritis) and fluids

I would also prescribe PRN analgesia, antipyretics (such as paracetamol) and antiemetics.

Thromboprophylaxis

Further management would be based on the results of the initial investigations

Question 4

Sepsis 6

Answer 4

Take three
Blood cultures, lactate and UO

Give three
Oxygen, antibiotics and fluids

Question 5

Her VBG is performed and shows the following key results:

pH 7.35 (7.35 - 7.45), HCO3 24 (22-26), Glucose 5.5 (4-8), Lactate 2.9 (<2.0)

Answer 5

Her VBG shows signs of hypoperfusion given her increased lactate of 2.9.

I would continue with fluid boluses to fluid resuscitate her and the antibiotics.

Question 6

24 hours later, the microbiology team call you to report that her urine cultures have grown an Extended Spectrum Beta-Lactamase (ESBL)-producing E. Coli. The pregnancy test is negative.

Answer 6

This confirms that infection is more likely to be pyelonephritis. I would work with the microbiology team to get her on the most appropriate antibiotic.

Question 7

What do you understand by the term ‘antimicrobial stewardship’ and the importance of antimicrobial selection for global public health?

Answer 7

Antimicrobial Stewardship:
A coordinated strategy to promote the responsible use of antimicrobials, including antibiotics, to improve patient outcomes, minimize resistance, and ensure sustainable effectiveness of these medications.

Global Importance:
Antimicrobial Resistance (AMR): Contributed to nearly 5 million deaths globally in 2019, disproportionately affecting developing countries.

Key Challenge: Inappropriate prescribing practices drive resistance.
Role of Stewardship: Ensures judicious prescribing as part of broader measures to combat AMR, benefiting global health systems and protecting future generations.

Question 8

You have one minute to hand over the patient to your registrar/consultant as if you were in the acute medical handover.

Answer 8

Situation: Hello, I’m ‘x’, the IMT1 on the acute medical take. I need to hand over a 27 year old female who has presented with suspected pyelonephritis.

Background: She presented with a 1 day history of flank pain and vomiting following recent treatment for a urinary tract infection by her GP.

Assessment: I have performed an A-E assessment in which she was found to be febrile, tachycardic and hypotensive. I have initiated treatment with IV fluids and broad spectrum antibiotics. Her VBG revealed a raised lactate and urine cultures have demonstrated a resistant E.coli organism.

Recommendation: I would greatly appreciate senior input for this patient in order to guide further investigation & management for suspected pyelonephritis. I plan to consult the microbiology team to ensure appropriate antimicrobial coverage and consider any imaging.