Uworld question re. Pyelonephritis next step

[Psych2014]

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Presentation of 35 yo woman with CVA tenderness, N/V, fever, chills, 102 fever, 17,000 wbc's, back pain, 100/60, UA + nitrites/many wbc's... what is the next best step in management?
A. Intravenous Pyelogram
B. Intravenous Antibiotics
C. Blood Cultures
D. CT abdomen
E. Abdominal Ultrasound
(My answer below, and my irritation with it being wrong...😱)


B. IVAB's because this lady is showing signs of sepsis, and needs empiric coverage NOW. Do Blood cultures and other dx's soon after.

They sayd C. Blood and urine cultures before AB's in case appearing septic. Huh? That's not the way we did it in ER or IM on the wards. At least empirical coverage is started asap to prevent sepsis and worsening, cultures take days sometimes to get back. How the hell can you wait to start AB's. Are they drinking drano or am I?

 

[zedx]

if i remember correctly, doesnt it mention you'd draw ctx and then give the IVAB, not that you would wait for the results to come back? Which would make sense, at least in my experience on the wards. anyone else?

 

[1trickpoknee]

I agree with zed. Know the bug to ensure proper coverage.

 

[synapse lapse]

If you give Abio and then draw culture, your culture may not grow out. Then if the patient remains septic you don't know what you're treating. As most questions on UW/Step 2 they want the next, best step. I know it's confusing, but we have to learn how to answer these questions the way they ask...and don't drink drano, it's bad for you 😛

 

[Scaredshizzles]

Presentation of 35 yo woman with CVA tenderness, N/V, fever, chills, 102 fever, 17,000 wbc's, back pain, 100/60, UA + nitrites/many wbc's... what is the next best step in management?
A. Intravenous Pyelogram
B. Intravenous Antibiotics
C. Blood Cultures
D. CT abdomen
E. Abdominal Ultrasound
(My answer below, and my irritation with it being wrong...😱)


B. IVAB's because this lady is showing signs of sepsis, and needs empiric coverage NOW. Do Blood cultures and other dx's soon after.

They sayd C. Blood and urine cultures before AB's in case appearing septic. Huh? That's not the way we did it in ER or IM on the wards. At least empirical coverage is started asap to prevent sepsis and worsening, cultures take days sometimes to get back. How the hell can you wait to start AB's. Are they drinking drano or am I?

Draw cultures and then antibiotics. Delaying treatment 10-20 minutes in this case is not as bad as potentially having a rare bug that you can't culture but which isn't responding too well to the antibiotics you are giving...If they don't respond to IV Abx, you're going to have to keep them admitted, and you know how much each days costs....As far as your thoughts on her being septic, she might be septic, but she is not in septic shock. Her blood pressure is kinda on the low side, but not so much for a younger woman... and no other indications in the history that she is in such dire conditions.

 

[Psych2014]

I appreciate the replies. I went and reviewed the question. 27% got it right. It's a good, subtle, tough question, and now I get the point. It was very gently worded.

Zedx, The Q did not say draw cultures then give abx. That would have made it simpler. But, as I've learned by you all's posts, that is the point that i was missing in my hasty thinking. I learned something here.

thanks for the careful thinking and feedback everyone, very good refining points. 👍

 

[Rendar5]

She's not too shocky assuming she's perfusing. BP drops any lower then I'd worry, but as is culture for potential management decisions, IV fluids, Zofran, and PO test. If she can keep down an antiobiotic she could even be sent home. If she's that pukey, I'd keep her for some IV antibiotics overnight and see how she is in the morning.

 

[Psych2014]

I was surprised they called it "septic shock" in the question (wish you could cut and paste Uworld for honest use), but I'm alsoa med3, so anything that looks like shock, I think is shock. I agree. Amazing how much no amount of book studying does what experience can do for a physician in training. Thanks for the input Zendar. Hope you are enjoying your residency.

 

[Rendar5]

I was surprised they called it "septic shock" in the question (wish you could cut and paste Uworld for honest use), but I'm alsoa med3, so anything that looks like shock, I think is shock. I agree. Amazing how much no amount of book studying does what experience can do for a physician in training. Thanks for the input Zendar. Hope you are enjoying your residency.

Thanks. So far so good🙂
My first case of pyelo (very classic) I thought it was an inpatient disease and was kind of shocked after discussing with my attending that you can treat this outpatient provided there is PO tolerance and an understanding of the need to return right away if there's no improvement within a day.


BTW, you are right to be concerned about shock in this patient. But even with septic shock, keep in mind that ABC's will come first (meaning fluids in this case), and labs are generally drawn during the IV inserts (depending on the model) before anything is hooked up to the catheter, so blood cultures will be obtained even before fluids or IV antibiotics can be given. So while ultimately in a septic shock case, early antibiotics are the most important definitive aspect of treatment, even in the mechanical order of things, they'll come after cultures are drawn and IV fluids.

 

[Psych2014]

Yep, they "suckered" me (which is their job) on the abx first sense of sepsis, and not being super experienced in the actual mechanics of the situation, I missed the fact that a blood draw does and should come first, for preservation of accuracy of culture testing.

 

[1trickpoknee]

To add to this interesting discussion has anyone had the question about the female who just started menses and inserted a tampon ~6 hours before presenting to the ER with Toxic Shock?

Doesn't it take a little longer (3-4 days) before TSS sets in?

 

[zedx]

so i had once thought...

 

[synapse lapse]

To add to this interesting discussion has anyone had the question about the female who just started menses and inserted a tampon ~6 hours before presenting to the ER with Toxic Shock?

Doesn't it take a little longer (3-4 days) before TSS sets in?

I thought so as well... got the question right but was confused. Have had a number of questions like that on UW. Just missed a question on measles cause I didn't know it was also known as Rubeola. I'm thinking, this girl has measles, but hey, only answer choice with measles (out of 15 choices) is atypical measles. Come to find out that only appears when a kid receives an inactivated measles vaccine, which was discontinued 40 years ago! Thanks a lot UW, like the questions aren't hard enough that I need to know alternative names for diseases or cryptic answers. Argh so frustrating.