Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving:
Flank pain (one-sided or bilateral pain in the lower back, near the kidneys)
Dysuria (pain or burning sensation during urination)
Frequency (urinating more often than usual)
Urgency (sudden, strong need to urinate)
Hematuria (blood in the urine) – may or may not be present
History of Present Illness:
Onset and duration of symptoms
Severity of pain (graded on a scale)
Associated symptoms:
Fever
Chills
Nausea and vomiting
Malaise (general feeling of discomfort)
Past medical history (urinary tract infections (UTIs), urinary abnormalities, kidney stones)
Sexual history (risk factors for UTIs)
Recent instrumentation (urinary catheterization)
Pregnancy (increased risk of UTIs)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be elevated with fever and tachycardia.
General examination: Assess for signs of dehydration and illness.
Abdominal examination:
Costovertebral angle (CVA) tenderness (localized tenderness in the lower back over the kidneys) – may be present on palpation.
Bladder distention (if unable to void)
Laboratory Findings:
Urinalysis:
White blood cells (WBCs): Elevated levels suggest infection.
Nitrates: May be positive if bacteria are present (not specific for APN).
Red blood cells (RBCs): May be present (hematuria).
Urine culture and sensitivity: Definitive test to identify the specific bacteria causing the infection and determine its antibiotic susceptibility.
Complete blood count (CBC): May show leukocytosis (high white blood cell count) in some cases.
Imaging Studies (may be ordered depending on presentation):
Ultrasound: Can assess for kidney size, presence of stones, or hydronephrosis (swelling of the kidney).
CT scan (with contrast) – if complicated APN is suspected: May be used to identify complications like abscesses or obstruction.
Assessment:
Summarize the findings and diagnose acute pyelonephritis based on clinical presentation, urinalysis, and urine culture results.
Consider the severity of the infection (uncomplicated vs. complicated APN with anatomical abnormalities or obstruction).
Identify potential risk factors for recurrent UTIs.
Plan:
Antibiotics: Choose an appropriate antibiotic based on urine culture results and local resistance patterns.
Hydration: Encourage oral fluids or administer intravenous fluids for hydration and to help flush out bacteria.
Pain management: Administer pain medication for flank pain and discomfort.
Antiemetics (if needed): To manage nausea and vomiting.
Follow-up:
Schedule a re-evaluation in (#) days (adjust based on severity) to assess response to treatment.
Repeat urine culture after completion of antibiotics to ensure eradication of bacteria.
Discharge Instructions:
Complete the full course of antibiotics as prescribed, even if symptoms improve.
Drink plenty of fluids to maintain hydration.
Void frequently and completely.
Consider cranberry products or prophylaxis (discuss with healthcare provider).
Follow up with a healthcare provider for re-evaluation and to address any risk factors for recurrent UTIs.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of acute pyelonephritis.