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Patient Name: John Doe
Date: September 15, 2022

John Doe presents with complaints of fever, nausea, flank pain, and increased urinary frequency for the past two days. He describes the pain as a dull ache on both sides of his back. He denies any urinary urgency, dysuria, or hematuria. He reports feeling fatigued and has experienced chills. John states he has not experienced these symptoms before, and they have been progressively worsening over the past 48 hours.

Vital signs:
– Temperature: 101.5°F
– Blood pressure: 120/80 mmHg
– Heart rate: 85 bpm
– Respiratory rate: 16 breaths per minute

Physical examination:
– General appearance: The patient appears tired and fatigued.
– Skin: No rashes or lesions noted.
– Head, eyes, ears, nose, throat: No erythema or discharge.
– Cardiovascular: Regular rate and rhythm, no murmurs.
– Lungs: Clear to auscultation bilaterally.
– Abdomen: Mild tenderness over both costovertebral angles.
– Genitourinary: No external abnormalities or tenderness on palpation.
– Musculoskeletal: No joint swelling or limited range of motion noted.

Based on the patient’s symptoms and physical examination, the preliminary diagnosis is pyelonephritis.

1. Laboratory investigations:
– Complete blood count with differential: to assess for leukocytosis and left shift indicative of infection.
– Urinalysis: to confirm the presence of pyuria, hematuria, or bacteriuria.
– Urine culture and sensitivity: to identify the causative organism and guide antibiotic treatment.

2. Imaging:
– Renal ultrasound: to evaluate for any structural abnormalities and assess the kidneys’ size and shape.

3. Treatment:
– Empirical antibiotic therapy: initiate with intravenous ceftriaxone 1g once daily to cover common pathogens, pending urine culture results.
– Adequate hydration: encourage increased fluid intake to promote urinary flow and flush out bacteria.
– Analgesics: prescribe acetaminophen for pain relief.
– Antipyretics: recommend ibuprofen to reduce fever if the patient’s condition permits.

4. Follow-up:
– Schedule a follow-up appointment in 48 hours to reassess the patient’s clinical response and review laboratory results.

1. Provide the patient with information on the importance of completing the full course of antibiotics to prevent recurrent infections and potential complications.
2. Advise the patient to increase fluid intake to maintain adequate hydration and promote urinary flow.
3. Discuss the significance of good personal hygiene before and after voiding to prevent reinfection.
4. Educate the patient about signs and symptoms that require urgent medical attention, such as worsening flank pain, persistent high-grade fever, and inability to tolerate oral intake.

Differential Diagnosis:
The differential diagnosis for the patient’s symptoms includes:
1. Urinary tract infection: Pyelonephritis is the leading diagnosis based on the presence of fever, flank pain, and urinary symptoms.
2. Renal calculi: Kidney stones can also present with similar symptoms, but the absence of dysuria and hematuria makes this less likely.
3. Appendicitis: Although the patient denies abdominal pain, it must be considered due to the location of the discomfort.

Pyelonephritis is a common urinary tract infection that involves the kidneys and can lead to significant morbidity if left untreated. Prompt diagnosis and appropriate management are crucial to prevent complications such as sepsis or renal damage.