A 68-year-old man is evaluated in the emergency department for severe left flank pain, hig… — USMLE Step 2 CK

A 68-year-old man is evaluated in the emergency department for severe left flank pain, high fever, and confusion. His medical history is significant for permanent atrial fibrillation, for which he takes apixaban. Two days ago, he visited an urgent care clinic for dysuria; a urine culture sent at that time is now growing *Escherichia coli* that is susceptible to ceftriaxone and resistant to ciprofloxacin.

On arrival, his temperature is $39.4^\circ\text{C}$ ( $102.9^\circ\text{F}$ ), blood pressure is $85/50\text{ mmHg}$ , heart rate is $125/\text{min}$ , and respiratory rate is $24/\text{min}$ . Physical examination reveals exquisite left costovertebral angle tenderness.

Laboratory studies show:

Test	Result
Leukocyte count	$22,000/\text{mm}^3$
Hemoglobin	$12.8\text{ g/dL}$
Platelet count	$210,000/\text{mm}^3$
Creatinine	$2.1\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$ )
INR	$1.1$

A bedside ultrasound demonstrates severe left hydroureteronephrosis but cannot identify the level of obstruction. The patient receives a $2\text{-L}$ intravenous fluid bolus and is started on intravenous ceftriaxone. Thirty minutes later, his blood pressure remains $88/52\text{ mmHg}$ and he is increasingly lethargic. Which of the following is the most appropriate next step in management?

Cystoscopy with retrograde ureteral stent placementAnswer
B
Image-guided percutaneous nephrostomy
C
Addition of intravenous vancomycin and switch to meropenem
D
Transport to radiology for a non-contrast CT scan of the abdomen and pelvis
E
Continued intravenous fluid resuscitation and observation

Answer

Cystoscopy with retrograde ureteral stent placement

This patient presents with obstructive pyelonephritis progressing to septic shock (urosepsis), which is a urologic emergency requiring immediate decompression of the infected collecting system. Bedside ultrasound confirms hydronephrosis, establishing the diagnosis. The two standard modalities for decompression are percutaneous nephrostomy (PCN) and retrograde ureteral stenting. However, this patient is actively taking apixaban, a direct oral anticoagulant. PCN requires tracting through the highly vascular renal parenchyma, which carries an unacceptably high risk of life-threatening retroperitoneal hemorrhage in a coagulopathic patient. Retrograde ureteral stenting avoids parenchymal puncture entirely and is the safest, most appropriate intervention to achieve source control.

Step-by-Step Solution

Assess the patient's hemodynamic status and clinical presentation.

The patient is in septic shock (hypotension refractory to fluids) secondary to an infected, obstructed kidney (fever, flank pain, hydronephrosis).

To recognize that this is a urologic emergency requiring immediate source control via decompression.

Evaluate the patient's medication list and coagulation status.

The patient is on apixaban, a direct oral anticoagulant (DOAC) that causes significant clinical coagulopathy despite a normal INR.

To determine the safety profile of invasive urologic procedures.

Select the safest method for collecting system decompression.

Retrograde ureteral stenting is chosen over percutaneous nephrostomy.

Stenting utilizes natural orifices and avoids puncturing the highly vascular renal parenchyma, minimizing the risk of catastrophic bleeding in an anticoagulated patient.

Key Concept

Emergent surgical decompression of obstructive urosepsis in patients on active anticoagulation.

Estimated Time:1m 30s

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