CASE 72: ABDOMINAL PAIN
History
A 38-year-old woman presents to the emergency department with a 2-h history of severe
abdominal pain. The pain is in the right loin and radiates to the right flank and groin and
the right side of the vulva. It is colicky and has made her vomit several times. Since the age
of 18 years she has had recurrent urinary tract infections, mainly with dysuria and fre-
quency, but she has had at least four episodes of acute pyelonephritis affecting right and left
kidneys separately and together. She has not had gross haematuria nor passed stones per
urethra. There is no other past history. Her mother had frequent urinary tract infections and
died at the age of 61 of a stroke. Over the years the patient has taken irregular intermittent
prophylactic antibiotics, but for only approximately a total of 20 per cent of the time. She
works in a travelling fairground and has no general practitioner (GP). Access to any previ-
ous medical records is not possible as she cannot remember the details of where she was seen
or treated. She has had some imaging of the urinary tract but is unsure of the details of the
investigations and their results.
Examination
She is ill – flushed and sweating with a pyrexia of 39.2°C. Her heart and chest are normal.
She is tender in the right loin. The blood pressure is 150/100 mmHg and funduscopy shows
arteriovenous nipping.
NormalHaemoglobin 14.3 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 85 fL 80–99 fL
White cell count 18.2% 109 /L 3.5–11.0% 109 /L
Platelets 365 % 109 /L 150–440% 109 /L
Sodium 136 mmol/L 135–145 mmol/L
Potassium 5.3 mmol/L 3.5–5.0 mmol/L
Bicarbonate 20 mmol/L 24–30 mmol/L
Urea 16.7 mmol/L 2.5–6.7 mmol/L
Creatinine 384 &mol/L 70–120&mol/LUrinalysis:'protein;'''bloodINVESTIGATIONS
Questions
- What diagnosis would you make?
- How would you interpret the results?
- How would you manage her now and in the long term?