WEEK 1 Pediatric Fever Flashcards
E.coli is a common organism that causes early onset sepsis in the neonate. true or false
true
All neonates with fever should receive empiric treatment with IV antibiotics. true or false
true
Early onset group B strep infection in a baby occurs in the first 24 hours to 2 weeks, and late onset occurs at 2 weeks up to 4 weeks of age. true or false
false
Signs and symptoms of sepsis in the neonate include progressive jaundice, poor feeding, and a temperature less than 35.5 degrees C. true or false
true
All neonates with fever should receive a full sepsis work up. true or false
true
What substance travels to the hypothalamus to signal the body to retain and generate more heat?
pyrogens
What part of the brain regulates body temperature?
hypothalamus
What is a fever in an infant under 2months?
Over 2 months?
Under 2 months = 100.4 or 38
Over 2months = 101 or 38.3
What are the differentials for fever? #6
- bacterial infection
- immunization reaction
- autoimmune & inflammatory disease
- cancer (lymphoma & leukemia)
- medication (abx & seizure)
- tissue damage
List the cause of febrile illnesses in neonates
- Infection acquired at delivery
- group B strep
- In nursery
- At home
- Pneumococcal
- Meningococcal
- Anatomic or Physiologic dysfunction
- Renal
- What is the gold standard for measuring temperature for children less than 3 years?
- When would you use an axillary temp?
- Rectal Thermometer
- Neutropenia cases (rectal temp can tear rectal skin and introduce bacteria)
The mother of a 12-month-old calls the clinic because her son has had a fever of 101.5 for 2 days, and she just noticed a rash on his torso. Which of the following questions is most helpful in determining if the rash may be due to a serious bacterial infection?
Does the rash blanch under pressure?
A 65-day-old male with no PMH presents for a fever of 101 degrees F for 8 hours. The infant received his 2 month vaccines yesterday. He is well-appearing and he has no red flags on history or exam. The nurse practitioner should
Order nothing and recheck the patient in 24 hours
A 40-day-old female born at term presents with a fever of 100.9 F for 12 hours. She has no PMH, takes no medications, she is feeding well, and has normal urine output and stool. Her ROS is negative. The child is nontoxic appearing and has an otherwise normal exam. The FNP understands that the infant will require:
UA, urine culture, and CBC/diff, PCT, CRP, and blood culture
How would you manage a low-risk well-appearing young infant 29-90 days old with Fever without a source?
CBC w/diff
Blood cultures
Catheterized UA & UC
PCT & CRP
CXR if not bronchiolitis
F/U 12-24 hours if labs normal & parents reliable
How would you manage a febrile Neonate (under 28 days) with fever?
Hospitalization
Full Septic work up
LP
CXR
Stool culture
THEN antibiotics an possibly acyclovir
How would you manage an ill-appearing febrile young infant (29-60 days) ?
Hospitalization with full work up
what labs for a febrile, well appearing infant (60-90 days old)?
U/A & U/C
CBC w/differential
BC
PCT
Any child under 2 years old with fever without focus warrants _____ ?
Urinalysis and Urine culture
What lab findings would constitute a preliminary diagnosis of UTI?
- Urine leukocyte esterase
- Nitrites
- Leukocyte count
- Gram stain
What do non-blanching rashes like petechiae and purpura indicate?
Bacteremia
What are some differential diagnoses for Fever without focus?
-
Bacterial infections (usually E. coli)
- Bacteremia
- Pneumonia
- UTI
-
Viral infection *most common*
- Influenza
- RSV
- Enterovirus
-
Noninfectious
- Kawasaki disease
- Autoimmune or inflammatory
- Immunization reaction
What antibiotics would you prescribe to a neonate with a fever without focus?
Ampicillin AND cefotaxime or gentamicin
What would you prescribe a neonate under 28 days if HSV was a concern?
Acyclovir
What would you prescribe a neonate under 28 days if meningitis was a concern?
Vancomycin
What is the antibiotic regimen for an infant (29 to 60 days) with fever without focus?
- Ceftriaxone or Cefotaxime
- Gentamicin for broader Gram – coverage
- Acyclovir for HSV concern
- Vancomycin for meningitis concern
What is the antibiotic regimen for an infant (61 to 90 days) with fever without focus
- Ceftriaxone and Cefotaxime
- Vancomycin if indicated
If an infant is less than 60 days old and labs are abnormal and CXR shows pneumonia…What additional testing should be done?
Lumbar Puncture
A well appearing infant (61-90 days) with fever without source needs to have what lab work done?
UA, UC, CBC w/diff, Blood culture, and inflammatory markers
An infant 61-90 days tests positive for RSV, what is their work up?
None
An infant 61-90 days tests positive for flu, what is their work up?
urinalysis and urine culture
What is the goal of testing infants 3months to 12 months?
R/O SBI
Which children require urine testing to r/o UTI?
All infants less than 3 months
American Heart Association 2017 Criteria for Kawasaki Disease
_Fever ≥ 5 days* and ≥ four of the following five principal clinical features** (most common to least common)_
-
Changes in lips and oral cavity, including
- reddened, cracked lips,
- strawberry tongue, and
- diffuse redness of oral and pharyngeal mucosa.
- Bilateral bulbar conjunctivitis, nonpurulent
- Polymorphous rash (maculopapular, erythema multiforme-like, and diffuse erythroderma) in extremities, trunk, or perineal regions
-
Changes in extremities
- Acute: edema of hands and feet, erythema of palms and soles
- Subacute: desquamation of fingers and toes
-
Cervical lymphadenopathy
- Usually unilateral
- ≥ one lymph node that is > 1.5 cm in diameter
Consider evaluating for incomplete Kawasaki disease in patients who lack full clinical features of classic Kawasaki disease; presence of coronary artery abnormalities confirms Kawasaki disease in most cases
* In patient with ≥ four principal clinical features, particularly with redness and swelling of hands and feet, diagnosis of Kawasaki disease may be made with 4 days of fever.
** Consider whether ≥ one principal clinical features were present during illness but resolved by time of presentation.
A 10-year-old child has a 1-week history of fever of 104 °C that is unresponsive to antipyretics. The primary care pediatric nurse practitioner examines the child and notes bilateral conjunctival injection and a polymorphous exanthema, with no other symptoms. Lab tests show elevated ESR, CRP, and platelets; cultures are all negative. What will the nurse practitioner do?
Order baseline Echo and another in 2 weeks
The clean catch urine specimen of a child with dysuria, frequency, and fever has a colony count between 50,000 and 100,000 of E. coli. What is the treatment for this child?
Treat with antibiotics for urinary tract infection
A 3-year-old child has just completed a 7-day course of amoxicillin for a second febrile urinary tract infection and currently has a negative urine culture. What is the next course of action?
Obtain a renal and bladder ultrasound
A dipstick urinalysis is positive for leukocyte esterase and nitrites in a school-age child with dysuria and foul-smelling urine but no fever, who has not had previous urinary tract infections. A culture is pending. What will the pediatric nurse practitioner do to treat this child?
Prescribe trimethoprim-sulfamethoxazole (TMP) twice daily for 3–5 days
A preschool-age child with no previous history has mild flank pain and fever but no abdominal pain or vomiting. A urinalysis is positive for leukocyte esterase and nitrites. A culture is pending. Which is the correct course of treatment for this child?
Order amoxicillin clavulanate
A 30-month-old girl who has been toilet trained for 6 months has daytime enuresis and dysuria and a low-grade fever. A dipstick urinalysis is negative for leukocyte esterase and nitrites. What is the next step?
Send the urine to the lab for culture
11
What are the red flags for a serious bacterial infection in an infant or child?
- Under 1 month old
- Ill appearance
- Pallor/mottled/ashen color
- Decreased Activity (poor feeding, no smile, decreased response to stimuli, lethargy, high-pitched cry)
- Tachypnea or Tachycardia
- Cap refill >3 sec
- Decreased U/O
- Underlying condition
- Unreliable caretakers
- Bulging fontanel
- Non-blanching skin rash
Which age of pediatric patients are at greatest risk for serious complications?
90 days or less
An 18-month-old male presents to your office with a temperature of 102.4. The parent says he has been feverish for the past two days with a slightly decreased appetite and energy level, but otherwise no complaints.
What are 5 differential diagnoses you would consider as a common reason for fever in this age of patient?
Upper Respiratory* Tract Disease (viral URI, otitis media*, & sinusitis)
Lower Respiratory Tract disease (bronchiolitis, pneumonia*)
GI Disease (enteritis*)
Musculoskeletal infections (cellulitis, septic arthritis, osteomyelitis*)
UTI* (especially E. coli)
Occult Bacteremia*
What diagnostic tests will you consider in a patient with a fever of unknown origin?
· CBC, ESR, CRP, Procalcitonin
· Serologic tests for specific diseases
· Blood Cultures
· U/A & U/C
· Mantoux skin test
· Xray
· LFTs
· Bone marrow biopsy for bacteria, fungus, AFB (mycobacterium)
· Echo for subacute endocarditis
- What are the indications for hospitalization in an infant or child with fever?
· Young Infant will be hospitalized if it has Box 28.9
- o Toxic Appearance/not consolable
- o Chronic Illness
- o Unreliable parents
- o Premature
- o A focal bacterial infection
- o Received systemic antibiotics within 72 hours
- o Postive U/A
- o WBC >15,000
- o ANC >1500 bands
- o Procalcitonin
- o CXR infiltrates
- o Positive Stool smear
- What questions are important to ask when gathering history on an infant with fever?
· Duration & Degree of fever
· Associated Symptoms (nonblanchable rash, change in activity, respiratory symptoms, V/D)
· Review of known exposures (family illness, other ill children, recent travel)
· PMH chronic illness (malignancy, splenectomy, shunt, indwelling catheter, immunologic disorders, SBI)
· Neonatal history of complications, prior abx, surgeries or hyperbilirubinemia
· Medications (antipyretics, antibiotics, herbs & dietary supplements)
· Immunization history (Hib & pneumo)
- What are treatment options for fever, both pharmacologic and non-pharmacologic?
Nonpharmacologic
- Hydration
- Reassurance
- Appropriate clothing
- Ambient temperatures
Pharmacologic
- Antipyretics - Acetaminophen or Ibuprofen
What is a complicated UTI?
Less than 2 years old
Upper urinary tract
History of medical problems
Abnormal anatomy
Drug-resistant pathogen
Fever, Toxicity, dehydration
UTI in a child younger than 6 months
What structural abnormality is most associated with UTI?
Vesicoureteral Reflux
What type of organism infection is most common in UTI in neonates?
What is the most common causative agent for UTI in general?
- Group B strep
- E. Coli then Klebsiella
What are the diagnostic criteria for UTI?
Infant 2-24 months
· U/A: leukocytes and/or nitrites
· U/C sterile catheterization or Suprapubic aspiration
When would you order a radiological workup for UTI?
· Children w/1st positive U/C & w/fever & systemic illness
· Children w/ 1+ infections of the lower urinary tract (dysuria, frequency, urgency, suprapubic pain)
How to remember the signs of Kawasaki disease?
CRASH & Burn
- Conjunctivitis
- Rash
- Adenopathy, Cervical
- Strawberry tongue
- Hands & Feet
- Burn = Fever
Describe Clinical Signs of Kawasaki’s disease
CRASH-Burn
-
Conjunctivitis
- bilateral
- nonpurulent
- Rash
- Polymorphic
- Trunk & Extremities
- Adenopathy,
- Cervical
- Unilateral
- Node >1.5cm
- Strawberry tongue
- Prominent Papillae
- Erythema oral mucosa & lips
- Hands and feet
- Swelling
- Erythema
- Desquamation 2 weeks after fever onset
- Burn = Fever
*
In a patient with a fever without focus, what tests would you order?
- U/A & U/C
- CBC w/diff, neutrophil count (ANC)
- Blood culture
- LFTs (if herpes suspected)
- CSF fluid
- CXR for respiratory symptoms
- Stool culture for blood or mucus in stool
- RSV or influenza PCR if in season
When would you not admit a child that has had an immunization within the last 24 hours?
Immunization was received in the last 24 hours
Temp <101.5F (38.6C)
What lab findings constitute a preliminary UTI diagnosis?
- Leukocyte esterase
- nitrites
- leukocyte count
- gram stain
What is the definition of a fever with unknown origin?
Temperature >101F (38C) or several occasions or more than 3 weeks duration
and
failure to reach diagnosis despite 1 week intensive investigations
What are common causes of fevers of unknown origins?
- atypical presentations of common disorders
- Infections
- Rheumatologic and connective tissue diseases
- juvenile rheumatoid arthritis
- Systemic Lupus Erythematosus
In children less than 6 years old, what are common causes of fevers of unknown origins? #5
- UTI/ pyelonephritis
- respiratory illness
- localized infection
- abscess
- osteomyelitis
- Juvenile arthritis
- Leukemia
In adolescents, what are the common causes of fevers of unknown origin?
- Tb
- Inflammatory bowel disease
- autoimmune disorders
- Abscesses
- Chlamydia
- Lymphoma
What diagnostic studies would you order for a fever with unknown origin
- CBC w/diff
- ESR, CRP, PCT,
- LFT
- Serologic tests for specific diseases
- Aerobic blood cultures
- U/A & U/C
- Mantoux skin test
- Xray of chest, sinus, mastoid, and GI
- Heterophil antibody & antinuclear antibody titer in older child
- Echo
When would you hospitalize a child with Fever of unknown origin?
- systemic illness
- failure to thrive
- very young
- parental anxiety
The majority of infants less than 3 months have a ___ infection
Viral
RSV and Influenza happen in ____ season
winter
Enterovirus occur in ___ and ____ season
summer and fall
What are signs of bacteremia with an occult infection in children?
nontoxic-appearing child whose blood culture is positive for a pathogenic organism
Febrile infants younger than ___ month (s) or any toxic appearing child aged ___ to ___ months should be admitted to the hospital for a completed sepsis work up
younger than ONE MONTH
or
toxic appearing aged 0 to 36 MONTHS
For fever without focus, what is “high risk” criteria
- Febrile neonate
- Any toxic appearing child
- <3 months w/ temp >101.5F (38.6C)
- <3months w/ Chronic illness
- Gestation <37 weeks & premature
- Given antibiotics in the last week
- 3-36 months old w/ temp 102.2F (39C)
- Fever w/Petechiae
What is the definition of a Fever without focus
Acute febrile illness with nonapparent fever etiology after careful H&P
In general, what are the most common causes of fever with unknown origin?
UTI/Pyelonephritis
respiratory illness
localized infections
juvenile arthritis
leukemia/lymphoma
What are differential diagnoses for fever with unknown origin?
- Infectious Disease
- Collagen-Vascular Disease (juvenile arthritis, SLE)
- Malignancy
- Drug Fever
- Nosocomial
- HIV
- Diabetes Insipidus
- Hyperthyroidism
- Inflammatory Bowel Disease
- Hematoma in a confined space
- anhidrotic ectodermal dysplasia
- Munchausen syndrome by proxy
How is Kawasaki’s disease characterized?
acute generalized systemic small and medium vessel vasculitis
Describe the acute phase of Kawasaki’s disease
- High fever more than 5 days; Fever lasts a total of 10 days
- Conjunctivitis; bilateral, nonpurulent, erythema
- Fissured lips
- Strawberry tongue
- Oropharyngeal mucosal erythema
- Maculopapular rash/morbilliform
- Cervical Lymphadenopathy; unilateral, >1.5cm, slightly tender, firm, fluctuant
- ST/Gallop rhythm/MR/AR
- Edema Hands and Feet
Describe the subacute phase of Kawasaki’s Disease
Begins when fever, rash, and cervical lymphadenopathy resolve
Days 11-25
- Desquamation hands, feet, groin
- Thrombocytosis/Cardiac Aneurysm occur
- EKG changes:
Describe the convalescent phase of Kawasaki’s disease
Day 25
- Symptoms resolved EXCEPT ESR elevation
- Bow lines on nails
- Onychomadesis (shedding proximal toe nails)
Diagnostic studies for Kawasaki’s disease
Diagnosis of exclusion
- CBC w/diff & PLT (high bands, anemia, plt count unusually high)
- CMP
- Inflammatory markers (CRP, ESR)
- LFTs (Elevated ALT, low albumin)
- U/A (look at wbc)
- Echo (r/o aneurysm)
What lab findings would you expect for someone with Kawasaki’s disease?
- Neutrophilia with bands
- Elevation ESR, CRP, and PLTs
- Elevated LFT
- Low albumin
- abnormal lipid levels
- anemia
- Leukocytosis
Life threatening KD may have leukopenia and thrombocytopenia
Differential diagnosis of Kawasaki’s disease
- Viral infections
- measles
- adenovirus
- EBV
- enterovirus
- influenza
- roseola
- Bacterial infections
- Cervical Adenitis
- Scarlet Fever/Strep
- Toxin-Mediated diseases
- staphylococcal scalded skin syndrome
- Toxic Shock Syndrome
- Hypersensitivity reactions
- Drugs
- SJS
- Mercury toxicity
- sJIA
How would you manage someone with Kawasaki’s disease?
- IV IG : controls vascular inflammation, down regulates antibodies
- high dose ASA: antiinflammatory & antiplatelet
- Baseline Echo; Repeat 2 weeks
- Cardiology referral
- Heart healthy diet
- Inactivated influenza vaccination
*no live vaccines for 11 months after IVIG
What are the clinical signs of pyelonephritis in an infant?
An older child?
Infant
- Fever
- Irritiability
- Vomiting
Older children
- Fever
- Bacteriuria
- Vomiting
- Flank pain
__ the most common cause of serious bacterial infection in infants younger than ____ months old with fever without a focus
UTIs
24 months
What is the definition of a complicated UTI?
UTI with fever, toxicity, and dehydration
OR
a UTI occurring in a child less than 6 months
Differential Diagnoses for UTI
- Urethritis
- Vaginitis
- Viral cystitis
- Foreign body
- Sexual abuse
- Dysfunctional voiding
- Appendicitis
- Pelvic abscess
- PID
**any child who has fever without a focus, Failure to Thrive, Chronic diarrhea, or recurrent abdominal pain should be worked up for UTI
What would you prescribe for a patient with uncomplicated cystitis more than 2 months old?
Bactrim
What would you prescribe for uncomplicated cystitis for a patient <3months old?
Amoxicillin
What would you prescribe for a recurrent UTI
Needs further evaluation
Renal or Bladder Ultrasound
How would you manage an infant >1month with uncomplicated pyelonephritis (well hydrated, no vomiting, no abdominal pain)?
Cefixime, cephalexin, or amoxicillin clavulonate
How would you treat an adolescent with uncomplicated pyelonephritis?
Amoxicillin clavulanate or ciprofloxacin
What would you order to determine if there is vesicoureteral reflux?
VCUG
Who would you not given Ibuprofen to?
Infants less than 6 months
What labs would you draw for an infant 29-60 days with a fever without source?
U/A U/C
BC
CBC w/diff
PCT
CRP
what labs would you draw for a fever without a source for an infant 60-90 days?
U/C
U/A
Also consider: CBC w diff, BC, PCT
In fever without focus for 60-90 days: If an immunization is within the past ____ and temp is < ____ work up can wait
If an immunization is within the past 24 hours and temp is < 101.5 work up can wait
What would you order if a child 0-24 months is exhibiting respiratory symptoms?
Influenza
RSV
CXR
Covid-19
What is the fever risk criteria for an SBI?
- Febrile infant <28 days
- Toxic child
- 1-3 months with rectal temp 101.5F or greater
- <3 months with chronic illness
- <3 months with focal bacterial infection, even with AOM
- Gestational age <37 weeks
- Antibiotic use within past 7 days
- <36 months with rectal temp 102.2 or greater and abnormal labs
- Petechiae
A 7-month-old fully immunized female presents to the office with fever. Mom reports she has “not been herself” and felt “a bit warm on the forehead for 2-3 days.” Vitals reveal a temperature of 39.2°C. Physical examination reveals a non-toxic infant who is irritable but able to be consoled. You perform a complete history and physical but are unable to identify a source of the fever. What is the first step in your approach to this child?
A: Obtain a urinalysis and urine culture.
B: Admit for observation and perform blood, urine, and CSF for culture.
C: Give an intramuscular dose of ceftriaxone.
D: Order acetaminophen 30 mg/kg and discharge the patient if the temperature comes down.
A. Obtain a U/A & U/C
Females at higher risk for UTI; fever >48 hours; fever greater than 101 (38)
Which of the following antibiotics should be prescribed for the empiric treatment of fever of unknown origin (FUO) in immunocompetent children?
A: Amoxicillin-clavulanate
B: Azithromycin
C: Isoniazid
D: Empiric antibiotics should not be used in the treatment of FUO
Answer D
immunocompromised do not sit on them for 3 weeks time, require an aggressive work up
What is the management of Kawasaki Disease
IVIG 1st line
Aspirin (1st line, continue 4-5 weeks, look for signs of bleedings)
Corticosteroids
Echo
NO LIVE VAX WITHIN 11 MONTHS OF KD
What is Leukocytosis? What are the causees of it?
High WBC count, usually neutrophils
Cause: viral, bacterial, fungal, parasites, cancer, meds
What is leukopenia? What are the causes of leukopenia?
low WBC, usually low neutrophils
Cause: Autoimmune disorders, medications, bone marrow conditions, cancer
What causes a high lymphocyte count?
Viral infection
EX: mono, cmv, hepatitis
What causes a low lymphocyte count?
Immune deficiency
What can cause neutropenia?
AA descent
Drug induced
Bone marrow disorder
Parents bring in a 20 month old boy to clinic today stating he has had three days of fever.
You complete your physical exam which appears normal other than a temperature of 101.4F in the office. The child does not appear toxic, but does appear to not feel well, is clinging to the mother, but is easily consolable. What will you order first?
Your urinalysis and culture come back normal. After a 2 more days, the parents bring the child back in and state the fever has persisted. Physical exam still shows no obvious source of infection. What will you order next?
WBC and lymphocytes are elevated..What do you do next?
- U/A & U/C
- CBC w/ diff
- Suggests Viral infection
The nurse practitioner is seeing a 54-day-old infant for follow-up after a visit to the emergency room (ER) yesterday for a fever of 100.9 degrees Fahrenheit. The infant is well appearing and has a normal exam today. Which of the following factors were likely included in the decision to discharge the infant home with close follow up?
a. He was diagnosed with a focal bacterial infection
b. He was treated with antibiotics 3 days prior to his ER visit
c. He was born at 36 weeks gestation
d. He had a normal urinalysis, white blood cell count and procalcitonin
d. He had a normal urinalysis, white blood cell count and procalcitonin
A 6-year-old child with no significant past medical history is being seen by the nurse practitioner for follow up for fevers of 101 to 102 degrees Fahrenheit for 2 to 3 weeks. The child is well appearing and has undergone urine testing, CBC with differential, complete metabolic panel, blood cultures and chest x-ray. All testing has been normal thus far. The nurse practitioner reevaluates the historical data and understands that is important to ask which of the following?
Select one:
a. Do you have any pets at home?
b. Was the child born at term and any complications with delivery?
c. Did the child receive an immunization within the past 2-3 weeks?
d. Is there any lead paint in your home?
A.
The rates of bacteremia have decreased in infants and young children for which of the following reasons?
Select one:
a. Increased sensitivity of lab testing
b. Routine administration of H. influenzae and S. pneumonia vaccines
c. Increased rates of breastfeeding
d. The availability of broad-spectrum antibiotics
B.
It is important for the primary care nurse practitioner to identify Kawasaki disease and promptly refer the child to the ER to prevent which of the following sequela?
Select one:
a. Coronary artery disease
b. Acute renal failure
c. Valvular heart disease
d. Glomerulonephritis
A.
Which of the following is included in the diagnostic criteria for Kawasaki disease?
Select one:
a. Fever of >100.4 for 3 days
b. Systolic heart murmur
c. Tonsillar edema and exudate
d. Polymorphous erythematous rash
D.
A 4-year-old female with no past medication history or history of UTI presents with fever, altered voiding pattern, urine malodor and abdominal pain. The child is well appearing and has a normal exam. A clean catch urine is obtained and is positive for leukocyte esterace, nitrite, white blood cells, and bacteria. A urine culture with sensitivities is ordered. Which of the following should be the next step?
Select one:
a. Await the results of the urine culture and treat if positive
b. Order a renal and bladder ultrasound
c. Treat empirically with oral antibiotics
d. Refer her to the emergency room for further evaluation
C.
What antibiotic will you prescribe for an 18 month old infant with symptomatic UTI?
augmentin or bactirm
A 5 year old is assessed for dysuria and frequency. Which antibiotic would the NP prescribe upon finding the UC positive for gram negative bacteria?
Ciprofloxacin (Cipro)
Trimethoprim-sulfamethoxazole (Bactrim DS)
Levofloxacin (Levaquin)
Doxycycline
Bactrim
An 8 year old boy with type 1 diabetes is being seen for a 3 days history of urinary frequency and nocturia. He denies flank pain and is afebrile. The UA is negative for blood and nitrites but is positive for a large amount of leukocytes and ketones. He has a trace amount of protein. Which of the following is the best test to order initially?
- UC and sensitivity
- 24 hour urine for protein and creatine clearance
- 24 hour urine for microalbumin
- IV pyelogram
UC and sensitivity
