Pyelonephritis refers to inflammation of the kidney caused by a bacterial infection.

It is usually caused by a bacteria called Escherichia Coli, which is the most common organism causing lower UTIs.

E. Coli are gram-negative, anaerobic, rod-shaped bacteria that are commonly found in the intestine and faeces.

From here, E.coli can easily spread to the bladder, then up through the ureters and into the kidney, triggering an inflammatory response.

Other causes include Klebsiella pneumonia, enterococcus, pseudomonas, staphylococcus saprophyticus, Candida albicans (fungal)

Risk factors for pyelonephritis include:

• Females
  • About 50-60% of women will have at least one UTI in their lifetime. This is because women have a shorter urethra, which means bacteria have a shorter distance to travel to reach the bladder.
• Anatomical abnormalities e.g. vesicoureteric reflux
• Pregnancy
• Diabetes mellitus

Symptoms: 

• Flank pain

• Nausea / vomiting
• Fever
• ± symptoms of acute cystitis (dysuria, frequency, urgency, haematuria)

Signs:

• Appear unwell
• Fever  ≥ 38 C
• May have tachycardia or hypotension
• Costovertebral angle tenderness 

• BEDSIDE
  • Urine dipstick
    • Leucocytes +ve
    • Nitrites +ve
    • May also be erythrocytes +ve
• PATHOLOGY
  • Urine Microscopy, Culture and Sensitivities (MCS)
  • ↑ WCC
  • ↑ CRP
  • Blood cultures
  • ↓ Decreased eGFR 
• IMAGING
  • USS or CT KUB to exclude other pathology such as abscess or kidney stones

If mild symptoms / hemodynamically stable:

• Disposition:
  • Outpatient
• Management:
  • Oral antibiotics e.g. amoxicillin + clavulanic acid, ciprofloxacin, cephalexin
  • Analgesia
  • Hydration
  • Safety-netting

If moderate to severe symptoms / hemodynamically unstable:

• Disposition:
  • Inpatient
• Management:
  • Resuscitation
  • IV antibiotics e.g. gentamicin, ceftriaxone, ampicillin or amoxicillin 
  • IV fluids

COMPLICATIONS

• Chronic Pyelonephritis caused by recurrent infections leading to scarring and damage to the kidneys. This can lead to chronic kidney disease. 

Urinary tract infections (UTIs) occur when bacteria—most commonly E. coli from the intestine—enter the urethra and travel up into the urinary tract.

In lower UTIs, the bacteria reach the bladder, stick to its lining, and multiply, causing inflammation known as cystitis. This leads to symptoms like burning during urination, urgency, and frequency.

If untreated, the infection can spread up the ureters to the kidneys, resulting in a more serious infection called pyelonephritis, which may cause fever, flank pain, and systemic illness.

Risk factors for UTIs include: 

• Females
  • About 50-60% of women will have at least one UTI in their lifetime. This is because women have a shorter urethra, which means bacteria have a shorter distance to travel to reach the bladder.
• Sexual activity
• Spermicides and diaphragms
• Pregnancy
• Post menopausal women 
• Urinary catheters
• Benign prostatic hyperplasia and neurogenic bladder
  • Due to incomplete bladder emptying
•  Diabetes mellitus
• Anatomical abnormalities e.g. vesicoureteric reflux

Symptoms: 

• Dysuria (or painful urination)

• Urinary urgency

• Urinary frequency

• Haematuria or blood in the urine

• Cloudy or foul-smelling urine

• Suprapubic pain

• Occasionally a low-grade fever

Signs:

• Mild suprapubic tenderness 

The presence of flank pain, vomiting and high-grade fever suggest upper tract involvement, such as pyelonephritis, and require urgent attention.

• BEDSIDE
  • Urine dipstick
    • Leucocytes +ve
    • Nitrites +ve
    • May also be erythrocytes +ve
• PATHOLOGY
  • Urine Microscopy, Culture and Sensitivities (MCS)
  • Consider STI screening
• IMAGING
  • USS or CT KUB (if recurrent UTIs)

• Disposition:
  • Outpatient
• Conservative:
  • Oral antibiotics e.g. trimethoprim, nitrofurantoin, cephalexin 
  • Analgesia
  • Hydration
  • Safety-netting

• COMPLICATIONS
  • Pyelonephritis
  • Urosepsis
  • Recurrent UTIs

The Mental State Examination (MSE) is a structured, comprehensive assessment to evaluate a patient presenting with mental health symptoms.

Just like we would perform a cardiovascular examination in a patient presenting with chest pain, we use the MSE in a patient presenting with mental health symptoms.

The MSE can be easily remembered using the acronym ASEPTIC: 

• Appearance & Behaviour
• Speech
• Emotion: Mood & Affect
• Perception
• Thought
• Insight & Judgement
• Cognition

It’s always important to conduct at Risk Assessment after the Mental State Examination. 

A stands for Appearance & Behaviour

Appearance refers to a basic description of the patient and can include:

• what they are wearing
• levels of personal hygiene
• body habitus
• physical signs of disease / harm

Behaviour refers to:

• how well the patient engages during the consultation
• their levels of eye contact
• facial expressions
• body language
• abnormal movements such as tremors / tics / involuntary movements / posturing

A patient with depression, may have poor self-care and hygiene, avoid eye contact and have psychomotor retardation (or slow movements / delayed responses to questions).

A patient with mania, may be wearing an extravagant outfit, be hyperactive, maintain intense unrelenting eye contact and have psychomotor agitation. 

S stands for speech.

The assessment of a patient’s speech can be further broken down into:

• Rate
  • Slow
  • Pressured (rapid speech which is difficult to interpret) 
• Quantity
  • Mute
  • Poverty of speech 
  • Excessive
• Tone
  • Monotonous
  • Tremulous
• Volume
  • Quiet
  • Loud
• Rhythm
  • Stammering
  • Stuttering
  • Slurring
  • Stilting

A patient with depression may have slow, quiet, monotonous and poverty of speech.

A patient with mania may have pressured, loud and confident speech that is difficult to interrupt

E stands for Emotion which includes Mood and Affect. 

MOOD

Mood is subjective and refers to the patient’s own assessment of their current emotional state.

This can simply be assessed by asking the patient “How are you feeling?”

Patient’s may describe their mood as low, anxious, angry, enraged, euphoric or apathetic. 

AFFECT

Conversely, affect is objective and refers to what the examiner observers during the consultation.

Affect includes:

• Patient’s apparent emotion
• Reactivity of their emotional state
  • Fixed
  • Restricted
  • Labile
• Intensity
  • Flat (no emotion) 
  • Blunted  (less emotion)
  • Exaggerated (heightened emotion)
  • Normal

It is always important to assess whether mood and affect are congruent i.e. does the patient’s report mood match their affect. If there is a discrepancy between mood and affect, we say they are incongruent.

Someone with depression may have a low mood with a blunted affect. 

Someone who is manic may have an elevated mood with a labile affect. 

Someone with schizophrenia may appear happy when describing upsetting events. This would be an incongruent mood and affect.

P stands for Perception

It refers to assessing the sensory information of the world around us.

There are different types of perceptual abnormalities: 

HALLUCINATION

A hallucination is when someone sees, hears, feels, smells, or tastes something that isn’t really there. It feels completely real to the person, even though there’s no external source.

For example, a patient with auditory hallucinations may hear voices but there is no sound present.

Hallucinations can happen in conditions like schizophrenia, psychosis, or drug use. 

PSEUDO-HALLUCINATION

A pseudo-hallucination is just like a hallucination but the individual recognizes that it is not real.

ILLUSION

An illusion is a misinterpretation of a real external stimulus. Unlike hallucinations (where there is no real stimulus), illusions occur when something is actually present, but the brain perceives it incorrectly.

For example, someone with psychosis may hear the sound of the wind and thinking that someone is whispering. 

DEPERSONALISATION

Depersonalization is a feeling of being detached or disconnected from yourself, as if you’re watching yourself from the outside.

This can be seen in post-traumatic stress disorder (or PTSD).

DEREALISATION

Derealisation is a sense that the world around them is not a true reality.

T stands for THOUGHT

This includes: 

THOUGHT CONTENT

Thought content refers to the actual substance of the patient’s thoughts. This can be assessed by asking the patient “what’s been on your mind recently”. 

• Delusions (fixed, false beliefs) 
• Obsessions
• Overvalued ideas 
• Suicidal or homicidal thoughts

THOUGHT FORM

Thought form refers to how a patient moves from one thought to another. In healthy individuals thought form should logical and at a steady pace.

Abnormalities of thought flow and coherence include:

• Loose associations where a patient moves rapidly from one topic to another with no apparent connect between the topics
• Circumstantial thoughts include lots of unnecessary and irrelevant detail but eventually come back to the point
• Tangential thoughts include digressions from the main conversation subject
• Flight of ideas refers to fast pressured speech when ideas run into one another, making it difficult for the observer to follow
• Thought blocking refers to a sudden cessation of thought, typically mid-sentence, with the patient unable to recover what they previously said
• Perseveration refers to the repetition of a particular response e.g. the patient keeps repeating their name in response to all questions
• Neologisms is when a patient has made up words which are unintelligible
• Word salad is when a patient speaks a random string of words without relation to one another

THOUGHT POSSESSION

• Thought insertion – a belief that thoughts can be inserted into the patient’s mind
• Thought withdrawal – a belief that thought’s can be removed from the patient’s mind
• Thought broadcasting – a belief that others can hear the patient’s thoughts

For example, a patient with schizophrenia may have delusions, loose associations, flight of ideas, thought insertion, withdrawal and broadcasting.

“I know that the government is putting thoughts in my head. I didn’t think of this idea to run for president — it’s like they’re controlling my mind and putting these ideas there, making me think I’m the only one who can save the world.”

I stands for Insight and Judgement

INSIGHT

Insight refers to the patient’s ability to understand their condition. 

It can be described as intact, partial or impaired.

JUDGEMENT

Judgement refers to the patient’s ability to make decisions or solve problems in their current psychological state. 

For example, you may ask them “what would you do if you could smell smoke in your house?” and assess their response as intact or impaired.

C stands for COGNITION

This should include an assessment of the patient’s:

• Level of consciousness – are they alert or drowsy?
• Oriented to person, time and place
• Memory (short and long term)
• Concentration
• Formal assessment
  • Mini mental state examination (MMSE)
  • Montreal Cognitive Assessment (MOCA)

A risk assessment should be undertaken in all patients presenting with a mental health condition. 

Risk can be broken down into:

RISK TO SELF

• Suicide risk including thoughts, plans and actions
• Self harm risk
• Vulnerability including substance abuse, homelessness, isolation 

RISK TO OTHERS

• Violence or Aggression including anger, hostility or threats of violence

Infectious mononucleosis is also known as glandular fever or mono. 

It is caused by Epstein Barr Virus (EBV), which is a member of the herpes virus family. 

EBV spreads through saliva, which is why kissing and sharing drinks or utensils is a common mode of transmission. 

The virus first infects the epithelial cells of the oropharynx (tonsils and salivary glands), then spreads to the blood stream where it  infects B lymphocytes cells.

The infected B cells then begin to proliferate and travel to surrounding lymphoid tissue in the spleen and lymph nodes.

Here, the body mounts an immune response releasing cytotoxic T cells which undergo massive activation and proliferation to handle the viral load. As they activate, they take on an atypical appearance with large, irregular nuclei.

This immune activation leads to hyperplasia of lymphoid tissue in the tonsils, lymph nodes and the spleen.

• Adolescents and young adults aged 15–25 years.
• Children can also get the disease, however they are commonly asymptomatic.
• Equally common in both males and females.
• 95% of people have had EBV infection by the time they are adults.

Symptoms: 

• Fever
• Sore throat
• Fatigue
• Rash secondary to commencing antibiotics (amoxicillin or cephalosporins)

Infectious mononucleosis is commonly mistaken for streptococcal pharyngitis which is a bacterial infection of the throat.

Patients with EBV are sometimes incorrectly prescribed antibiotics such as amoxicillin or cephalosporins. 

This can lead to the development of a very itchy, generalised maculopapular rash that often starts 2 to 3 days after commencing the antibiotic. This can be a hallmark feature that someone has a infectious mononucleosis rather than a bacterial throat infection.

The rash is self limiting and is not a true drug allergy so patients are usually be able to tolerate penicillin in the future.

Signs:

• ↑ Temp

• Bilateral posterior chain cervical lymphadenopathy

• Tonsillar enlargement

• Splenomegaly 

• BLOODS
  • ↑  White cell count (WCC)
  • ↑ Atypical lymphocytes
  • ↑ AST
  • ↑ ALT

EBV Serology

Monospot Test

The Monospot test was previously used to test for EBV. It has now been replaced by EBV Serology.

The Monospot test was used to detect heterophile antibodies, which are IgM antibodies often produced by the body in response to infection. They are not specific to the EBV antigen.

The monospot test works by mixing the patient’s serum with animal red blood cells. If heterophile antibodies are present, they cause the RBCs to clump and this was a positive test.

There are three disadvantages of the Monospot test: 

1. Had read manually and was subjective to operator error
2. Low Specificity
   • Heterophile antibodies are not specific to EBV and are seen in other viral illnesses such as CMV, Toxoplasmosis, HIV and malignancies 
3. Low Sensitivity
   • Heterophile antibodies may not be present in the first or second week of illness, and therefore could be falsely-negative early on

Disposition:

• Outpatient

Supportive Care:

• Self-limiting infection (lasting 2-3 weeks)
• Rest
• Fluids
• Analgesia
• Avoid alcohol due to liver derangement
• Avoid contact sports for 3-4 weeks due to risk of splenic rupture

Complications:

• Splenic rupture
• Glomerulonephritis
• Haemolytic anaemia
• Thrombocytopenia
• Chronic fatigue
• In certain individuals, latent (or dormant) EBV infection is also associated with certain cancers, such as Burkitt’s lymphoma.

Acute cholecystitis refers to inflammation of the gallbladder caused by a gallstone blocking the cystic duct (95% of cases). 

In 5% of cases, acute cholecystitis can be caused without the presence of gallstones. This is known as acalculous cholecystitis. 

Risk factors include the 5 F’s:

• Female
• Fat 
• Fertile 
• Forty
• Family history 

Symptoms: 

• Right upper quadrant (RUQ) pain 
• Shoulder tip pain (referred)  
• Fever
• Nausea
• Vomiting

Signs:

• ↑ Temp

• ↑ HR 

• ↑ RR 
• RUQ tenderness 
• Murphy’s sign +ve

• BLOODS
  • ↑  White cell count (WCC)
  • ↑ C-reactive Protein (CRP)
  • ↑ AST
  • ↑ ALT
• IMAGING
  • USS Abdomen
    • Gallstones
    • Thickened gallbladder wall
    • Pericholecystic fluid

• Disposition:
  • Inpatient (Emergency Department / General Surgical Ward)
• Conservative:
  • Nil by mouth (NBM)
  • IV fluids
  • IV antibiotics
  • Analgesia
• Surgical Management:
  • Laparoscopic cholecystectomy (can occur within 72 hours of admission. Can also be done 6-8 weeks after acute episode)