EM Forum Case #110 "2 by 2 by 2"
by Charlene Babcock Irvin, MD, FACEP
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A 22 y/o female presents with fever and weakness. She also has right sided
abdominal pain. She has been sick for 2 days.
ROS: Fever, x 2 days. Vomited once yesterday. Today feels nauseous, but no
vomiting. She has a mild cough.
No sore throat, neck pain, chest pain, shortness of breath, problems with
bowels, or rashes. She denies vaginal discharge, or pain with urination, but
does note that her urine feels ‘hot’ when she has a fever. She has a younger
sister with a bad ‘cold.’
PMH/ FH/SH: All negative.
PE: WDWN obese female, lying on cot. She is slightly diaphoretic (she got
Tylenol at triage).
VS: 130/78, HR=110, RR=20, Temp=102 PO
HEENT: PERRL, pharynx normal, MM slightly dry, neck supple, TM normal.
Heart: Tachycardia, no murmurs
Lungs: Clear bilaterally, no rales
Abd: Obese, soft, minimal tenderness to deep palpation in Right upper quadrant
laterally.
NSVK: R CVA tenderness
Ext: Negative, skin no rashes
Neuro: normal.
U/A sent at triage is back: SG: 1.030, Positive Leukocyte esterase, positive
nitrite, many bacteria, WBC=280, RBC=28,
squamous epithelial cells = 4
Questions:
1. What is the 2 by 2 rule for treatment of pyelonephritis?
2. Should you send a urine culture?
3. How would your management change if she was pregnant?
4. Besides Bactrim or Ciprofloxin, what other antibiotics can be used?
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