Pyelonephritis


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 in A&E

Patient: 35 year old female patient who has presented to A&E feeling generally unwell with back pain and vomiting.

Task:

– Take a focused history from the patient

– After 6 minutes you will be asked a series of questions by the examiner.

– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 35 year old women who has been feeling really unwell for the past 3 days. If asked why you have come to hospital, explain that you have been vomiting this morning and have been generally unwell for the last 3 days, you have never experienced anything like this before. You have not been eating or drinking and have not been able to sleep because of the pain.

The pain is in your right lower back / right lower abdomen. It does not radiate anywhere else, it is constant in nature.

You have had horrible sweats. The sweating has been so bad that you have had to change your bed sheets 4 times in a day. Your partner has taken your temperature and said it was 40 degrees. You have been shivering / shaking intermittently.

You started vomiting this morning and you have no idea what caused this. You are vomiting any water or food that you have been trying to have.

If asked you have not passed any fluids in the past 2 days, you assume because you have not been able to drink anything.

In the past week you have been having experiencing pain when trying to urinate. You have not had any treatment for this.

You are sexually active with your partner, you have been together for the past 5 years. You had an STI check 3 weeks ago which was negative. You are not experiencing any discharge or abnormal PV bleeding. Your last period was 2 weeks ago and your cycles are regular.

PMH:

No past medical history

No previous operations

DH:

No regular medications

No known drug allergies

SH

You do not smoke but use a ‘vaper’ / e-cigarette

You drink 2 bottles of rose per week

You live with your parents

You work for a local charity in the social media department

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint
Loin pain
Temperatures
Rigors
Vomiting


Urology symptoms
Dysuria
Nocturia
Poor urinary stream
Frequency
Incomplete voiding
Incontinence


Associated features
Recently unwell
Weight loss
Anorexia
Lethargy


PMH Past medical history
No past medical history
No previous operations
Candidate specifically asks about: DM, immunosuppression


DH Drug history

No regular medications
No known drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


ICEF
Explores ideas, concerns, expectations, feelings


Question Given your history, what are your differentials?
Pyelonephritis
Lower urinary tact infection
Appendicitis
Pelvic inflammatory disease
Other appropriate answer


Question
Please review the patients observations and then decide what investigations would you like to do in this patient

Urine dip
MC&S if urine dip positive
Pregnancy test
Bloods = FBC / U&Es / LFTs / CRP / Amylase
Blood cultures
Ultrasound KUB (kidneys, ureter and bladder)


Question
Review the following investigations and state what your most likely diagnosis is

Acute pyelonephritis


Question Does this patient need admission to hospital?
Yes


Question
What would be your management for this patient. Show candidate prescribing guidelines if mentions antibiotics

Co-amoxiclav 625mg (or 1.2G) 8 hourly
Gentamicin IV 7mg/kg/day (max 560mg)
Paracetamol 1G QDS
Codeine 30-60mg QDS PRN
IVF - normal saline 1L over 8 hours
IV antiemetic e.g Ondansetron 4mg TDS
Can eat and drink
VTE assessment
Senior review



Score