DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Acute pyelonephritis.
2. Dehydration, corrected.
BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old female who was well until 11 days prior to admission when she started developing fever, described as intermittent, along with abdominal pain and rectal pain. The fever was rising from 99 to 103. She was seen in our office at the time and examined. There was no focus of infection. Urine bag did not show any white cells in the urine. The parents were advised to observe her and to report to us.
A day later, her fever shot up to 103. She was taken to the emergency room. At the time, she was seen in the emergency room. She underwent lab work, including urine, catheterized urine sample, all did not yield anything positive. She was discharged, and the parents were advised to increase fluids, as the patient at the time was afebrile during that period of time, but complaining of abdominal pain. She was given also an enema, which yielded large amount of stool, and the patient did feel well for 24 hours.
However, two days later, her blood culture started growing gram-positive cocci, and the patient was called back in. At the time, she underwent a repeat urinalysis and blood culture. She was given Rocephin 600 mg, which was followed by some improvement over the following 24 hours. However, during that weekend, her fever returned. She became lethargic, and when they called us, we decided to send her back to the emergency room for further care.
At the time, her urinalysis revealed a large amount of wbc’s, which did not exist prior, documented at around 400 wbc’s or more. A culture was taken; however, the patient was already on Rocephin at the time. She was admitted. Based on those findings, the patient was started on IV fluids, and a renal and bladder ultrasound along with a VCUG was scheduled. The patient was kept on Rocephin during admission along with IV fluid for hydration. She did well. The renal ultrasound came back negative. Her VCUG also later came back negative, and her urine culture came back negative; this culture was done after she received a dose of Rocephin in the emergency room.
Based on those findings, it was likely that the patient did have pyelonephritis. However, she has no urinary tract anomalies to be concerned about, and she was discharged to home with a prescription of Suprax to continue for a period of 10 days and to report to us in two weeks. The parents were also advised to monitor urine on a monthly basis for the following three months and then every two months for the following six months.
