peter90036
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44yo woman flank pain fever chills dysuria
urinalysis shows wbc, wbc casts
cbc leukocytosis
1. next step?
a. urine culture
b. treatment
c. imaging
d. reassurance
2. initial imaging should be?
a. CT
b. MRI
c. US
d. IVP
3. initial treatment should be?
a. ciprofloxacin
b. tmp-smx
c. ceftriaxone
d. penicillin
Edited by peter90036 on 03/27/08 - 01:25 PM
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| dr.wad
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1- urine culture ,then give emperical tx ,then change according to culture.
2- u/s
3-tmp/smx .....ampicillin and gentamycin is another option.
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| doc649
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1] culture
2] USG
3] IV cipro
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| nyimalay
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a
c
c
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| Justice
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1. b. treatment (urine is to be collected for culture but you start empiric a/b immediately as culture will last 48-74 hr at least, acute pyelonephritis is a medical emergency)
2. c. US
3. a. ciprofloxacin
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| dr.wad
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Justice wrote:
1. b. treatment (urine is to be collected for culture but you start empiric a/b immediately as culture will last 48-74 hr at least, acute pyelonephritis is a medical emergency)
2. c. US
3. a. ciprofloxacin
hi , justice ...long time since ur last post.... hope u r doing well..be around .
ok , regarding the q ....i guess it is like a puzzle...the q is very easy but i dont know if he means by urine culture is to wait the results or not...
CMDT says ( urine and blood cultures are obtained ro identify the causative organism..........iv antibiotics are started prior to obtaining results).
regarding the third q ..yes it is iv cipro
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| Justice
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dr.wad wrote:Justice wrote:
1. b. treatment (urine is to be collected for culture but you start empiric a/b immediately as culture will last 48-74 hr at least, acute pyelonephritis is a medical emergency)
2. c. US
3. a. ciprofloxacin hi , justice ...long time since ur last post.... hope u r doing well..be around . ok , regarding the q ....i guess it is like a puzzle...the q is very easy but i dont know if he means by urine culture is to wait the results or not... CMDT says ( urine and blood cultures are obtained ro identify the causative organism..........iv antibiotics are started prior to obtaining results). regarding the third q ..yes it is iv cipro
Hey my friend... I will be around for sure as I am after step 3 now...
I agree with you... I solved this puzzle by deciding what's the BEST step... IV A/B is the best step anyway even if I don't take urine/blood for cultures... Urine for cultures cannot be the best answer unless I am an idiot. In addition, I would consider this option ONLY if it was blood for cultures, not urine...
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| peter90036
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next step as in step by step 1, 2, 3 
if it was "most important" step i think that would be the treatment
culture is imp to get any possible organism and sensitivity to AB
maybe should have included "blood+urine" culture in the question, sorry
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| inkspot
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1 B start treatment with emperical and send culture. emergency is dealt first. never wait till culture results.
2 C non invasive easily accessible. ( but what exactly are you looking @ ?) small kidneys? hydronephrosis? impacted stones?
3 B
emperic treatment is with septran , flouroquin are for refractory dz.
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| peter90036
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all i've been seeing (FA, harrisons) is fluoroquinolone first (harrison says continue with tmp-smx, but start FQ/if severe pyelo FQ IV)
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| peter90036
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not sure what should be picked on exam tmp-smx or fq ...
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| Justice
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peter90036 wrote:next step as in step by step 1, 2, 3 if it was "most important" step i think that would be the treatment culture is imp to get any possible organism and sensitivity to AB maybe should have included "blood+urine" culture in the question, sorry
I do not buy this reasoning, and will argue by using your way of mentation:
the urine was already obtained for urinalysis, right??? You, actually, have UA charts... You can not take it second time for culture, you ALREADY HAVE IT!!!
So, NEXT (1->2->3), according to you, start IV A/B, and adjust protocol after you know the causative organism...
And, I don't see how you discriminate BEST from the MOST IMPORTANT... Can you explain???
Edited by Justice on 03/27/08 - 12:02 PM
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| inkspot
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kaplan medical says any antibiotic that covers gram neg is better.
they organized it as: fluroquinolones, tmp/smz, ampicillin/genta or 3rd gen ceph.
Board and Wards for step 2 / 3 says: tmp/smz then fluroquinolones.
CMDT 2007 put it this way:
any of these drugs!
Ampicillin, 1 g every 6 hours, and gentamicin, 1 mg/kg every 8 hours Intravenously 21 days $780.00 not including intravenous supplies
Ciprofloxacin, 750 mg every 12 hours Orally 21 days $229.00
Ofloxacin, 200–300 mg every 12 hours Orally 21 days $270.00
Trimethoprim-sulfamethoxazole, 160/800 mg every 12 hours2 Orally 21 days $46.00
So going by cost  TMX is cost effective. I am sure ecfmg wont ask such question!
Edited by inkspot on 03/27/08 - 12:07 PM
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| peter90036
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hah, you got me there Justice !
i should mentate more deeply before making ambiguous questions :P
but isnt this right?
clinical > UA > U culture > tx > adjust
?
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| Justice
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peter90036 wrote:
hah, you got me there Justice !
i should mentate more deeply before making ambiguous questions :P
but isnt this right?
clinical > UA > U culture > tx > adjust
?
So, this is a home-made question, isn't it?
Well, it really depends upon the situation. You, of course, have to obtain urine ASAP, but what is the PT has an empty bladder? In addition, if this is the office visit, you write the orders, ask the PT to collect urine in a sterile container (cannot put a catheter because of acute inflammation) and also order IV a/b STAT...
In your sequence, I would put UA and U/for cultures as a single action, but the time gap between these two and IV a/b maybe just a few minutes...
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| peter90036
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well ok but this is a test, not real life
and without it being specified in the q stem you can't assume it - patient can pee, you can take urine, can place iv in the tiniest veins.
and so as i modified the Q now,
it not being specified... i reckon the next step is urine culture
yes/no... public opinion is....?
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| Justice
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peter90036 wrote:
it not being specified... i reckon the next step is urine culture
yes/no... public opinion is....?
If you ask: take urine for UA/cultures, then YES
If you ask simply: urine cultures vs IV a/b, then NO, IV a/b would go first provided that you ask about NEXT BEST STEP in management of the SP
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| mjl1717
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I like urine and blood cultures first.. empirical treament after this, because I.D. will say "why did you treat him first, without cultures you know better then that"
Also Levaquin is the poular one now!
Good basic q..
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