Case 2

A 66-year-old woman with non-insulin-dependent diabetes mellitus attends the ED complaining of 3 days of pain in one flank and feeling hot.

What other symptoms would you ask her about?

Further questioning reveals she actually started feeling unwell 5 days ago when she had burning on passing urine. She had suffered from cystitis in the past and had been given medicines by her GP previously and thought this was the same problem. She has been taking Trimethoprim.

What condition well described in diabetic patients may she have been suffering from when her dysuria started?

Is this a complicated or uncomplicated infection and why?

On examination, she is febrile at 38.3, pulse 96 and has moderate tenderness in her left loin. Her BP is 110/70.

What immediate investigations would you perform?

Her WCC is 15.4. Often patients with pyelonephritis can be managed with the first dose of antibiotics administered intraveneously then sent home with oral antibiotics. Why isn’t this patient a candidate for this?

Describe your choice.

Which of the following would be reasonable antibiotic choices?

What local complication are you particularly concerned about in this patient? How would you investigate for it?