A 60 year old female presents to your OPD with complaints of pain in left lumbar region since 6 months and supra pubic pain .

 A 60 year old female presents to your OPD with complaints of pain in left lumbar region since 6 months and supra pubic pain .

She also gets burning of micturition from time to time.

Her BP is 140/90 mm Hg.

Temp : 37.2 C

No remarkable findings in Respiratory, Gastrointestinal , Cardiovascular and Nervous Systems.

1 .Which investigations would you like to perform?

2. What are the findings in Ultrasound ?

3. How will you treat this patient

Answers given in comments section.

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1 . Which investigations would you like to perform?

As this patient has problems with likely origins in urinary tract including pain in left lumbar region which is most likely originating from left kidney and supra pubic area which could be urinary bladder pathology,

An ultrasound of abdomen would be of good value to see any pathology in kidneys , ureter or bladder.

An x ray kub can show a bladder stone or a large kidney stone but will not be able to exclude any other kidney of bladder pathology which can only be visualized by an ultrasound.

Other investigations would be haematological such as Full blood count, Sugar levels and urea to see any presence of acute bacterial infection or find out any underlying cause of recurrent UTIS such as Diabetes Mellitus.

Urea is needed to see if any long term kidney damage has been done due to recurrent UTIs.

2. What are the findings in Ultrasound ?

Ultrasound showed small left kidney with scarring , with irregular outline and impared cortico medullary Differentiation likely due to chronic pyelonephritis secondary to recurrent UTIs leading to chronic kidney damage.

Also urinary bladder wall is thick suggestive of cystitis .

3. How will you treat this patient

This patient has got active cystitis and UTI and will require antibiotics for treatment.

Also for the left kidney we need to take opinion from urologist whether it would be of benefit to remove left kidney after determining the patients renal status and determining how much percentage of left kidney is functioning as well as determining Glomerular Filtration Rate and Creatinine clearance.

First line antibiotics:

Fosfomycin (Monurol) 3-g single dose

Nitrofurantoin (macrocrystals) 100 mg twice per day for five days

Trimethoprim/sulfamethoxazole (Bactrim, Septra) 160/800 mg twice per day for three days.

Second line antibiotics :

Ciprofloxacin (Cipro) : 250 mg twice per day for three days

Ciprofloxacin, extended release (Cipro XR) 500 mg per day for three days

Levofloxacin (Levaquin) 250 mg per day for three days

Ofloxacin 200 mg per day for three days or 400-mg single dose.

Third line antibiotics :

Amoxicillin/clavulanate (Augmentin) 500/125 mg twice per day for seven days

Cefdinir (Omnicef) 300 mg twice per day for 10 days.

Cefpodoxime 100 mg twice per day for seven days.