Immunocompromised is common among approximately 20% of patients

Immunocompromised is the impairment of the immune system
which can be congenital or acquired (Tandogdu, Cai, Koves, Wagenlehner &
Bjerklund-Johansen, 2016). In this case, the patient suffered from acquired
immunodeficiency due to previous chemotherapy to treat his melanomas. The
urogenital tract is composed of cellular and non-cellular innate immune
components ensuring the sterility of the urinary tract and some parts of the
genital tract. However, in immunocompromised patients, urogenital system is
exposed to a higher prevalence of common and rare infections. Urogenital
complications that immunocompromised patients suffer from include UTI,
epididymitis, condylomata of the urethra, prostatitis, in addition to renal
abscess and other renal related complications (Okafor, 2012).

The infectious causes of pyelonephritis can be
confirmed by urinalysis which shows bacteriuria and or pyuria, and a urine
culture showing a substantial concentration of uropathogen (Johnson &
Russo, 2018). Asymptomatic bacteriuria or asymptomatic urine infection is also
common among otherwise healthy female, and in female and male with
genitourinary tract abnormalities. Asymptomatic bacteriuria is recognised to be
common in some populations and frequently associated with inflammation of the
urinary tract, a hypothesis which indicates that asymptomatic bacteriuria
substantially contributed to the burden of chronic renal diseases including
pyelonephritis (Nicolle, 2016). Pyelonephritis usually manifests suddenly with
signs and symptoms of both systemic and bladder inflammation. This patient did
not have a fever or other bladder symptoms such as urinary frequency, dysuria
and urgency, which is common among approximately 20% of patients (Johnson &
Russo, 2018). Clinical presentations of pyelonephritis and disease severity
varies among patients with mild flank pain with low-grade and sever to septic
shock (Talan et al., 2016).

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On our arrival, the patient requested to be given
narcotic analgesic medication and refused transportation as he was unaware of
the nature and seriousness of his condition. Therefore, my mentor conducted the
VIRCA assessment to ensure the validity of his decision as he could have
altered mental status due to possible infections. The elements of this
assessment are voluntary, informed, relevant, capacity, and advice (Clinical Quality
& Patient Safety Unit, QAS, 2016). My mentor further informed him about
what are other possible causes of his condition, for instance, renal cancer and
renal stone, and how it could potentially influence his health. The patient
then agreed to be transported and admitted to a hospital for further
examination. My mentor remained calm and professional although it was very
difficult and unreasonable to convince the patient for transportation.

Pyelonephritis can be successfully treated with oral
medications on an outpatient basis; however, it is important for paramedics to
consider other possible causes and educate patients suffering from acute
pyelonephritis. My mentor continuously educated and provided advice for the
patient en route to the hospital; this includes providing basic education on
maintaining sexual and personal hygiene and maintaining adequate hydration
(Chivima, 2014)

For a patient complaining of flank pain or tenderness with a positive
urinalysis showing bacteriuria, pyuria and both with and without fever and
voiding symptoms, pyelonephritis can be an appropriate presumptive diagnosis.

However, other probable causes of flank pain or tenderness with or without a
fever I briefly examined below.

1.    Appendicitis is the inflammation of the
vermiform appendix (D’souza & Nugent, 2016); the clinical presentation of
appendicitis includes central abdominal pain that radiates to the right side of
the abdomen and worst on palpation. In addition to feeling hungry, nauseous,
and vomiting, and having a fever are other common signs and symptoms
(Livingston, 2015). There are no clinical signs which could have reliably
diagnose appendicitis, as the patient was mildly nauseous and complained of
aching sensation in the flank area worst on palpation. 

2.    Kidney stones or urolithiasis can often
remain asymptomatic, kidney stone pain is often characterised as spasmodic that
begins at the loin area and radiates to the ipsilateral flank, iliac fossa and
inguinal region (Strittmatter, Gratzke & Stief, 2015).  However, the most common presenting symptom
is renal colic that was not evident in this case. Renal colic is triggered by
tension in the renal capsule, collecting system, or ureter and can radiate with
the sympathetic nerves along the subcostal, iliohypogastric, ilioinguinal, or
genitofemoral nerves. The patient may also have intermittent and paroxysmal
attacks with associated nausea and vomiting, and fever when the stone causes
uropathy obstruction, in addition to haematuria and urinary retention
(Al-mamari, 2017).

3.    According to Dean (2017), the most common
clinical presentations of a patient with renal cancer include haematuria, mass
or lump in the kidney area, sudden weight loss, fever, diaphoresis, persistent
loin area pain, lethargy, loss of appetite, and a general feeling of poor
health. The differential diagnosis of renal cancer was disproven in the patient
assessment, because not adequate information collected suggesting this

4.    Renal vein thrombosis is the formation of a
blood clot in the renal vein; the clinical presentations of this condition vary
with the degree and speed of venous occlusion. Renal vein thrombosis can
sometimes remain asymptomatic; whereas, some patients might complain of
non-specific symptoms for instance nausea, vomiting and weakness (Jou, Jong,
Hsieh & Kang, 2014). In some severe cases, patients may complain of
specific symptoms including upper abdominal and flank pain, offensive smelling
urine, fever or haematuria. Additionally, scrotal pain in male caused by
thrombosis induced varicocele is common (Yildiz, Nieuwenhove, Doyen & Tombi,
2016). Although this patient did complain of flank pain and nausea, no other
clinical manifestation strongly suggested renal vein thrombosis.