Code Status case · Intermediate · Premium
Flank pain in a 33-year-old woman
“My right side and back really hurt. I've had chills since yesterday.”
“Three days of discomfort with urination and frequency, now right flank pain and chills. She vomited twice this morning.”
Your challenge
Layla's trouble started three days ago with burning when she passed urine. Now her right side and back hurt, she has had chills since yesterday, and she vomited twice this morning. A bladder infection that has climbed higher is the obvious thought, but a kidney stone, appendicitis and a twisted ovary all sit on the same side of the body. Choosing an antibiotic that actually reaches the right place, and deciding whether she can manage at home, is where this case is won or lost.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Acute Pyelonephritis
Lesson 1
Fever and Flank Pain Suggest Kidney Infection
Urine tests support infection but cannot tell you whether it reaches the kidney.
- Pyelonephritis is an infection of kidney tissue
- Fever and flank tenderness suggest pyelonephritis
- A urine dipstick can support infection but cannot locate it
- Culture urine first but do not delay antibiotics
Lesson 2
Infected Obstruction Needs Urgent Drainage
Antibiotics and resuscitation continue while drainage is arranged.
- Image for poor response, abscess, or obstruction
- Infected obstruction needs urgent drainage
- Normal creatinine does not exclude obstruction
- Drain with ureteral stent or nephrostomy
Lesson 3
Choose an Antibiotic That Reaches Kidney Tissue
A cystitis drug does not automatically treat renal tissue.
- Consider ceftriaxone if oral therapy may fail
- Check fluoroquinolone safety and resistance
- TMP-SMX only if susceptible
- Avoid nitrofurantoin or fosfomycin for pyelonephritis
- Choose antibiotics by culture and local resistance
Lesson 4
Home Care Needs Stability and Oral Treatment
Pregnancy and obstruction are exceptions.
- Discharge needs stability, oral intake, and follow-up
- Vomiting or obstruction may need admission
- Pyelonephritis in pregnancy usually needs admission
- Switch to oral therapy if improving and tolerating it
- Assign responsibility for checking the urine culture
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Layla is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.