Transcription - 20260210T 13-27.mp3

I'm michelle duffy +1 474747 32 year old lady investigations oh that was good good they're really good holy shit how accurate is it you guys got them urine emcee and is awaited yeah and yellow is it honey yeah bone profile normal use and ease normal with creatinine at baseline lfts alt of 46 but remained normal crp of 8 no previous measurements on our system urea normal ast 38 phosphate normal full blood count awaited blue top sent but not processed venous blood gas ph 7.38 with base excess - naught 0.8 and lactate 1.1 normal sports wait is like he doesn't know what this is observations temperature 37.3 blood pressure 115 over 90 respiratory rate 16 sats 98% pulse 109 hi suzanne I'm rob I'm a medical doctor who's listening to you how are you I'm well I'm not I'm sorry what's been happening tell me what's out of it just it was last week mhmm went to the gp because I think I was pregnant but I had the the the the send them all up I think it was the the the same okay and then it completely happened like we've of infections and that before so it was on the right hand side I've exposed and infections they did the level of thinking oh yeah I'm an idea before we did perfect and I mean violently so I and you've been vomiting before with them yeah yeah mhmm and and tell me more so you said pain when did it all start the just the urine the burning and the like urge to pee mhmm and then I went in pain like in a while back when we started was a good couple of days I'd been to the gp and like the thursday he'll have done the urine for the second time and over the weekend we dipped your urine yeah oh you got good no blood I had some blood tests which are not too bad okay so you've got some slightly raised markers of infection in keeping with the possibility of a kidney the but the rest of them your liver function tests are fine are you feeling about the pregnancy alright yeah surprised or glad or fourth so big surprise yeah alright but I just I just of course can't really think about it yeah no it's put me like put my mind away for that yeah I bet I've no slept for about 3 nights can we get the answers at all and tell me about your life more generally who lives at home with you me and 3 kids I'm not a adult mhmm uk I mean I think that's fine with me yeah okay so I'm gonna keep pressing to your chest rest for me and side pain now yeah and it's on this side yeah husband done it on this yeah other side as well yeah poor thing yeah this one's a rust it's like a constant pain you know shocks in the car and things like that that's really sore and you had some fevers at home is that right yeah really high fevers shivering shaking shaking last night was like can't remember where it was but but again I don't know if that was a I had a fever yesterday anyway mhmm I don't know yeah fine can I touch your tummy at the front is that okay you're about to take anything off okay that's fine function tests are as I say normal good 1 of the tests is slightly higher than it has been for you before mhmm but it doesn't look like it's a gallstone or anything like that based on those tests okay so a little bit less tender on this side now than no that's that's that's side yeah see when I'm sitting out there I'm still thinking I'm moving about the chair and pain it's like constant constant niggle I see your tongue is that alright that's alright thank you so what shall we do about it I don't know try some different antibiotics shall we yeah let me do a bit of working out which ones are the right ones to get on to will I get them in here I will go home I can get you them and I think looking at your blood test there's nothing that needs to keep you in the hospital good which is good yeah so I think I think it's good to have some blood tests and make sure there's nothing else going on yeah doesn't look like you got a stone because you'd have some blood in your wee if you have a stone you'd be like well no that's that's a different type of pen altogether fine you know what yeah fine yeah she's got some blood at all what's your number pain relief please yeah of course the doctor let's see what we'd suggest in urinary tract pyelonephritis k triamoxazole ciprofloxacin not to be used in pregnancy so if pregnant cephalexin orally or ceftriaxone iv right we're not gonna use ciprofloxacin so we could give you some cephalexin that'll be good won't it mhmm and that's safe in frequency I'll just make a 100% sure and then should we scan your kidney and make sure that it looks okay and you haven't got a stain yeah I'll see if we've got a slot today to do it if not I could bring you back to have it done we could make sure there's nothing else going on does that sound alright yeah it's fine cool pregnancy not known to be harmful good so that's good isn't it that's as positive as they'll get yeah great so I'll get you some cat waxing from the pharmacy I'll get you some painkillers have you had anything since you've here you've had some paracetamol yeah think it haven't really done it a bit sleepy that was that ibuprofen and diclofenac can be really good okay avoid using first and second trimesters unless essential fine I'm already on amitriptyline for my that's right so that's about and how much codeine are you on it gives me 15 mg okay fine so we could bring that up we could double that to 30 couldn't we because that's gonna be a good thing to take yeah in pregnancy isn't it not gonna be damaging at this stage in pregnancy so is that does that sound reasonable yeah would you like 30 mg of codeine now please is that did you get the codeine tablets or did you get the 1 mixed with paracetamol it gave me the tablets but I don't have any paracetamol at home go ahead I can put that on the prescription for you or you can I don't know if you oh you're pregnant so you won't pay for prescriptions have you got booked yet yeah I'm on the universal clearance team okay yeah great then it sounds like a plan then yeah should I get those things sorted for you I'll see if we can get you scanned today yeah and I'll come up with the description and let you know what the plan is and the plan it and then we'll get you out of here thank you sound good yeah thank you thank you thank you you doctor nott do you an ultrasound scan example same if you wanted 1 for a patient tell people do they have like same day slots that they reserve for us or anything like that or no not really so they have same day slots for dvt scans and stuff chronic then what if they do have a yeah fine it's not it's not I just wanted to just find her to tell you make sure she's had a stay which has had stays before yeah you could always kind of tell them that the discharge dependent needs to do it today yeah just make it thank you sweet she no she has some codeine is that alright got some codeine no some codeine for her pain I'm gonna give her some codeine for her infection and then we are sorted kefs relax in if you can get it if not we can just give it to her as a just give it to her as a patient just give her some codeine so she's not in pain then we can get her out of here is that alright yeah alright and then no thank you let's take a look at that let's see I think it's a white palpation prescription very well 60 depression left parietal arthritis partially treated with antibiotics but intolerant of co amoxiclav secondary to vomiting plan alternative antibiotics with cephalexin which is safe in pregnancy analgesia outpatient ultrasound scan to exclude stone however seems unlikely given no hematuria on urine dip analgesia before discharge

Presenting Complaint:
Left loin pain with dysuria and vomiting

Past Medical History
• Previous urinary tract infections
• Chronic pain (on amitriptyline and codeine)
• Early pregnancy (recently confirmed)

Diagnosis:
Left-sided pyelonephritis in early pregnancy

I had the pleasure of meeting Michelle Duffy in Same Day Emergency Care today.

Ms Duffy is a 32-year-old lady who attended with a one-week history of dysuria, urinary frequency and right-sided loin pain. She initially presented to her GP last Thursday with suspected urinary tract infection and was started on co-amoxiclav. However, she has been intolerant of this antibiotic, experiencing significant vomiting. She has had previous urinary tract infections and reports that this episode feels similar to previous infections she has experienced.

The pain is located in the right loin and has been constant over recent days, exacerbated by movement. She has experienced high fevers at home with rigors, particularly last night. She has been unable to sleep for approximately three nights due to her symptoms. She has recently discovered she is pregnant, which came as a surprise to her.

She lives at home with her three children. She is currently on amitriptyline for chronic pain and takes codeine 15mg as needed.

On examination, she was alert and comfortable at rest. Temperature 37.3°C, BP 115/90, HR 109, RR 16, saturations 98% on room air. She had significant tenderness over the right renal angle with percussion tenderness. Abdominal examination revealed some right-sided tenderness but no peritonism. The left side was less tender. Chest examination was unremarkable.

Investigations:
Urine MC&S: Awaited
Urine dip: No blood, leucocytes present
Venous blood gas: pH 7.38, base excess -0.8, lactate 1.1 (normal)
Bone profile: Normal
U&Es: Normal with creatinine at baseline
LFTs: ALT 46, AST 38 (mildly elevated but otherwise normal)
CRP: 8
Full blood count: Awaited (blue top sent but not yet processed)

Plan:
1. Discharge on cephalexin (safe in pregnancy) as alternative antibiotic for pyelonephritis, having been intolerant of co-amoxiclav
2. Increase codeine to 30mg for analgesia (safe in early pregnancy)
3. Prescribe paracetamol for home use
4. Arrange outpatient ultrasound scan of renal tract to exclude renal calculus (though seems unlikely given absence of haematuria on urine dip)
5. Safety-net advice to return if symptoms worsen, persistent vomiting, or increasing pain
6. GP follow-up for review of urine culture results and clinical progress
7. Continue with antenatal care as arranged with universal clearance team

Summary

Investigations

Plans