What signs of infection and obstruction should be monitored in a 90-year-old female with non-obstructing renal stones?

Signs of Infection and Obstruction to Monitor in a 90-Year-Old Female with Non-Obstructing Renal Stones

In a 90-year-old female with non-obstructing renal stones, close monitoring for signs of infection and obstruction is critical as these complications can rapidly progress to urosepsis and significantly increase morbidity and mortality. 1

Signs of Infection to Monitor

Classic Signs

• Fever (>37.8°C orally, >37.5°C rectally, or 1.1°C increase over baseline) 1
• Rigors/shaking chills 1
• Flank pain or tenderness at the costovertebral angle 1
• Nausea and vomiting 1

Atypical Signs in Elderly Patients

• Mental status changes/delirium (particularly important in the elderly) 1
• New or worsening confusion 1
• Decreased functional status or mobility 1
• Fatigue or weakness (new or worsening) 1
• Decreased fluid or dietary intake 1

Urinary Symptoms

• Change in urine color or odor 1
• Cloudy urine 1
• Macroscopic hematuria 1
• Dysuria 1
• Increased urinary frequency or urgency 1
• Decreased urinary output 1

Signs of Obstruction to Monitor

Clinical Signs

• Sudden onset of severe flank pain 1
• Nausea and vomiting 1
• Development of hydronephrosis (detected on imaging) 1
• Urinary retention 1
• Suprapubic pain 1

Laboratory Findings

• Rising serum creatinine (indicating renal function deterioration) 1
• Leukocytosis (elevated white blood cell count) 1
• Elevated C-reactive protein 1

Monitoring Protocol

1. Regular Vital Signs

   • Temperature monitoring at least twice daily
   • Blood pressure and pulse monitoring
   • Respiratory rate assessment

2. Laboratory Monitoring

   • Urinalysis (assess for white and red blood cells and nitrite) 1
   • Urine culture if urinary tract infection is suspected 1
   • Complete blood count to monitor for leukocytosis 1
   • Serum creatinine to assess renal function 1

3. Imaging Follow-up

   • Ultrasound to evaluate for development of hydronephrosis 1
   • Consider CT scan if symptoms worsen or patient remains febrile after 72 hours of treatment 1

Special Considerations for Elderly Patients

• Elderly patients often present with atypical symptoms of infection and obstruction 1
• Changes in mental status may be the only sign of infection in this population 1
• Increased risk of urosepsis due to age-related immune changes 1
• Higher risk of adverse effects from medications used to treat infections 1
• Increased risk of falls during episodes of infection 2

When to Seek Immediate Medical Attention

Immediate medical attention is required if any of these signs develop:

• Fever with rigors/shaking chills 1
• Clear-cut delirium or significant mental status change 1
• Severe flank pain 1
• Signs of sepsis (hypotension, tachycardia, tachypnea) 1
• Inability to maintain oral hydration 1

Prevention Strategies

• Maintain adequate hydration 1
• Consider methenamine hippurate for recurrent UTI prevention in women without urinary tract abnormalities 1
• Avoid unnecessary catheterization 1
• Prompt treatment of any urinary tract infections 1
• Regular follow-up to monitor stone status 3

Careful monitoring is essential as prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial, as the latter can swiftly progress to urosepsis, especially in elderly patients 1.