Quick answer
How should I present a complicated pyelonephritis case on rounds?
Open with his diabetes and the fever, flank pain, and vomiting, since diabetes is what makes this complicated rather than routine pyelonephritis. Give the elevated white count, creatinine above his likely baseline, lactate, and the urinalysis findings before naming complicated pyelonephritis. End with admission, renal-function-adjusted antibiotics, and urgent imaging to exclude obstruction.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation once initial blood tests and urinalysis return, before urine culture or imaging.
A supervising physician deciding on admission and the urgency of imaging for obstruction.
History, blood tests including white cell count, creatinine, eGFR, and lactate, and urinalysis with microscopy. Urine culture and imaging are not yet available.
About 80 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Lee is a 65-year-old man with type 2 diabetes who presents with worsening fever, flank pain, and vomiting.
His fever, flank pain, and vomiting have been recently worsening, along with generalized fatigue, without a clear alternate explanation.
His only significant history is type 2 diabetes, and he takes no regular medications; he is a non-smoker and social drinker.
His white blood cell count is elevated at 17.8, creatinine is elevated at 1.6 with an estimated GFR of 46, and lactate is elevated at 2.7. Urinalysis shows 3+ leukocyte esterase, positive nitrite, and greater than 50 white blood cells per high-power field, all supporting a urinary source.
My diagnosis is complicated pyelonephritis with an elevated lactate raising concern for early sepsis, occurring in a patient with diabetes who is at higher risk for a severe course, renal abscess, or treatment failure.
I would admit him, obtain blood and urine cultures, resuscitate as needed, and start renal-function-adjusted empiric IV antibiotics after cultures are drawn when feasible. I would obtain urgent imaging to exclude an infected obstruction or renal abscess and would not delay decompression if one is found.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name the diabetes and the acute infection together
“Mr. Lee is a 65-year-old man with type 2 diabetes who presents with worsening fever, flank pain, and vomiting.”
Why it belongs: Naming his diabetes alongside the classic pyelonephritis symptoms in the opening sentence signals that this is complicated, not routine, pyelonephritis from the very first sentence.
This is a 65-year-old with a kidney infection.
Mr. Lee has diabetes and presents with worsening fever, flank pain, and vomiting.
Why: Naming the diabetes upfront tells the listener this needs a higher level of concern than uncomplicated pyelonephritis.
History of present illness
Give the progression and systemic symptoms
“His fever, flank pain, and vomiting have been recently worsening, along with generalized fatigue, without a clear alternate explanation.”
Why it belongs: Worsening symptoms with systemic fatigue, rather than a single stable complaint, support an evolving infection that needs urgent assessment rather than outpatient management.
He's had fever and pain for a while.
His fever, flank pain, and vomiting have been recently worsening, along with generalized fatigue.
Why: Naming the worsening trajectory is more useful than a static description.
Relevant background
Confirm diabetes as the complicating factor
“His only significant history is type 2 diabetes, and he takes no regular medications; he is a non-smoker and social drinker.”
Why it belongs: Diabetes is the specific factor that reclassifies this from uncomplicated to complicated pyelonephritis and raises the risk of a more severe course or treatment failure.
He has diabetes.
His diabetes is the specific factor that makes this complicated pyelonephritis rather than a routine case.
Why: Explaining why the history matters is more useful than stating it in isolation.
Objective data
State the labs and urinalysis findings
“His white blood cell count is elevated at 17.8, creatinine is elevated at 1.6 with an estimated GFR of 46, and lactate is elevated at 2.7. Urinalysis shows 3+ leukocyte esterase, positive nitrite, and greater than 50 white blood cells per high-power field, all supporting a urinary source.”
Why it belongs: The elevated lactate raises concern for early sepsis, and the reduced eGFR both confirms kidney involvement and directly affects antibiotic dosing, while the urinalysis triad supports a urinary source for the infection.
His labs and urine tests both looked infected.
His lactate is 2.7, creatinine is 1.6 with an eGFR of 46, and urinalysis shows 3+ leukocyte esterase and positive nitrite with over 50 white cells per field.
Why: Exact values let the listener judge both the severity and the renal-dosing implications.
Assessment
Commit to the diagnosis and its sepsis risk
“My diagnosis is complicated pyelonephritis with an elevated lactate raising concern for early sepsis, occurring in a patient with diabetes who is at higher risk for a severe course, renal abscess, or treatment failure.”
Why it belongs: Naming the sepsis concern explicitly, not just 'a urinary infection,' is what should drive admission and urgent reassessment rather than outpatient oral antibiotics.
This is a bad UTI.
This is complicated pyelonephritis with an elevated lactate raising concern for early sepsis.
Why: Naming the sepsis concern reflects the actual urgency of this presentation.
Plan
State admission, renal-adjusted antibiotics, and imaging for obstruction
“I would admit him, obtain blood and urine cultures, resuscitate as needed, and start renal-function-adjusted empiric IV antibiotics after cultures are drawn when feasible. I would obtain urgent imaging to exclude an infected obstruction or renal abscess and would not delay decompression if one is found.”
Why it belongs: Adjusting antibiotic dosing to his reduced eGFR and actively imaging for obstruction, rather than assuming a straightforward infection, addresses the two ways this case could deteriorate quickly if missed.
I'll admit him and start antibiotics.
I would admit him, start renal-adjusted antibiotics after cultures, and obtain urgent imaging to exclude an obstructed infected kidney.
Why: Naming both the renal dosing adjustment and the obstruction screen shows a more complete plan.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Urine and blood culture results
Say: “Urine and blood cultures are not yet resulted in this simulation, and I would use them to confirm the organism and narrow antibiotic therapy once available.”
Empiric antibiotics are started now, but the regimen should be reassessed once culture and sensitivity results return.
Imaging for obstruction or abscess
Say: “Imaging to assess for an obstructing stone or renal abscess is not part of this simulation and is an urgent priority given his risk factors.”
An infected obstructed kidney needs emergent decompression and cannot be identified by labs alone.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Worsening fever, flank pain, and vomiting in a diabetic patient | Lead | This combination defines the acute problem and why it is classified as complicated. |
| Type 2 diabetes as the only significant history | Lead | This single factor is what reclassifies the case from uncomplicated to complicated pyelonephritis. |
| Non-smoker, social drinker | Omit | This detail does not change the acute management decision. |
| Elevated lactate of 2.7 | Lead | This raises concern for early sepsis and should not be buried among other lab values. |
| Urinalysis triad of leukocyte esterase, nitrite, and pyuria | Include | It supports a urinary source while culture results are still pending. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
Why does his reduced eGFR matter for antibiotic choice?
Many antibiotics used for pyelonephritis require dose adjustment based on kidney function, and his eGFR of 46 means standard dosing could risk toxicity; renal-function-adjusted dosing is needed rather than a fixed standard regimen.
How do you know this isn't just a routine UTI?
Fever, flank pain, and systemic symptoms distinguish pyelonephritis from a lower urinary tract infection, and his diabetes and elevated lactate further classify this as complicated pyelonephritis with sepsis risk, requiring admission rather than outpatient treatment.
What would make you worry about an obstructed kidney?
Persistent fever despite appropriate antibiotics, worsening pain, or a clinical picture out of proportion to the initial presentation would raise concern for an infected obstruction or abscess, both of which need urgent imaging and possible decompression.
Self-check
A 30-second check before you present
- Name the diabetes alongside the classic symptoms in the opening sentence.
- State why this is 'complicated,' not routine, pyelonephritis.
- Give white count, creatinine, eGFR, and lactate with exact values.
- State the urinalysis findings that support a urinary source.
- Name the sepsis concern explicitly if lactate is elevated.
- State that antibiotic dosing is adjusted for renal function.
- State that imaging for obstruction or abscess is an urgent priority.
- Note that cultures are pending and will guide narrowing therapy.
Common presentation problems
Repair the habits that make a case hard to follow
Treating this as a routine urinary tract infection
Repair: State explicitly why diabetes and the lab findings make this complicated pyelonephritis.
Starting antibiotics without adjusting for reduced eGFR
Repair: State that dosing is being adjusted for his kidney function.
Omitting imaging for obstruction
Repair: State that urgent imaging is planned to exclude an infected obstruction or abscess.
Ignoring an elevated lactate as just 'a lab value'
Repair: State the sepsis concern it raises explicitly.
Frequently asked questions
Oral case presentation questions
Should I mention a formal sepsis score?
Yes, if your program uses one, mentioning it shows a structured approach to his elevated lactate; otherwise, stating the lactate value and your concern is sufficient.
Do I need to name a specific antibiotic?
State that renal-function-adjusted empiric therapy is planned; the specific agent depends on local resistance patterns and should be confirmed with your institution's protocol.
How long should this presentation be?
This worked example targets about 80 seconds. A patient in overt septic shock would need a shorter, more urgent initial presentation.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case urology_041. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- 2025 Guideline Update on Complicated Urinary Tract InfectionsInfectious Diseases Society of America · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: