• Diabetic Pyelonephritis
  • Radiology:Renal ultrasound which shows no kidney stone nor obstructive pathology. I concur with this interpretation.EKG:Not indicated given no cardiopulmonary complaintsPROCEDURES:None indicated. ED COURSE, DISCUSSION & MEDICAL DECISION MAKING:-Pyelonephritis– DDx. Given nature of presenting complaint (CC), pt was evaluated emergently for the following to determine if need for emergent diagnostics/interventions. When upon my eval, the hx/exam was exceeding clear that more emergent morbid/mortal pathologies were not in any reasonable refined ddx to this pt's presentation, further work up was not unnecessarily pursued to prevent putting pt at – in my professional opinion – were not indicated risks and outweighed benefit. Guidance was by consideration and appreciation for pt's best interest. Pyelonephritis, diabetic pyelonephritis, emphysematous pyelonephritis, pyelonephritis with nephrolithiasis, urinary tract infection, appendectomy, ovarian pathology,– A/P:– ED Course: Intravenous fluid administered with improvement of blood pressure IV antibiotics initiated Given diabetic pyelonephritis with mildly elevated beta hydroxybutyrate rate, subcutaneous insulin was administered. Patient did not have significant enough laboratory abnormalities that an insulin drip was required at this time. – Diagnostically: (aspects of evaluation emphasized given significant contribution to MDM): Leukocytosis, Urinary analysis consistent with urinary tract infection. Urine culture sent with follow-up mechanism Elevated glucose concerning for poorly controlled diabetes and pyelonephritis thereby requiring IV antibiotics and observation No evidence of obstruction on radiographic evaluation of kidneys therefore no "pus under pressure "therefore no emergent intervention by urology required at this time. Minimally elevated beta hydroxybutyrate, no anion gap BUN to creatinine elevated when compared to prior meeting criteria for a AKI– Therapeutically: Intravenous fluids, IV antibiotics– MDM: Suspect diabetic pyelonephritis. Given poorly controlled diabetes and risk for deterioration, patient requires IV antibiotics and observation to ensure appropriate trajectory of improvement clinically. Considered emphysematous pyelonephritis however clinically will sufficiently well and no evidence of such on sonographic evaluation. Not consistent with urinary tract infection given no systemic signs of infection. Not consistent with nephrolithiasis given no radiographic evidence of nephrolithiasis. Considered appendectomy however given benign abdominal exam and alternative diagnosis of pyelonephritis the pretest probability for appendicitis is sufficiently well that the risks of CT outweigh the potential benefits. Additionally considered ovarian pathology-specifically ovarian torsion however given alternative diagnosis found and history is more consistent with pyelonephritis, further diagnostics including diagnostic laparoscopy is not indicated at this time. Considered sexually transmitted infection however patient does not have high risk sexual risk features therefore with alternative diagnosis and without symptomatology concerning for sexually transmitted infection, will treat for most likely diagnosis of diabetic pyelonephritis rather than STI– Diagnosis: Diabetic pyelonephritis, elevated beta hydroxybutyrate, AKI– (most consistent with dx above wth understanding for diagnostic limitations due to emergent setting of encounter) – Suspected this diagnosis given urine analysis consistent with infection, systemic signs of infection, flank pain and known diabetes with elevated glucose and minimally elevated hydroxy butyrate– Dispo: Admitted Kindly accepted by Kmil -please see admission order for further detailsRe-EvaluationOn sepsis reevaluation, sepsis re-evaluation was preformed within 2 Hours of identification of courseSEPTIC SHOCK FOLLOW UP EVALUATIONDATE: 4/7/2018TIME: w/in 2 hrs of identification of sourceFOCUSED CLINICAL ASSESSMENT: Sepsis re-evaluation was performed.Supplemental Documentation: Pulse Ox Interpretation by me: Normal, no significant (<90%) hypoxia as interpreted by me I have visualized the imaging and agree with the Radiologist's interpretation of any imaging that may have been performed in this evaluation.————————————————————————–FINAL IMPRESSION:Diabetic pyelonephritisCONDITION: GuardedDISPOSITION:Admitted as detailed above and in admission order in regards to time and name of clinician for transfer of careADMITTED Indication: Diabetic pyelonephritis———————————————————–SUPERVISION: Discussed with attending.Obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physicianCOUNSELING: Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeuticsand plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered. Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible. Patient advised to follow up with PMD for re-evaluation to ensure improvement, also to ensure that optimize outpatient management of pathologies that prompted requirement to ED, and to ensure that incidental findings be followed up on non-emergent basis. I advised patient of the following incidental findings -specifically of findings suggestive of poorly controlled diabetes- which need follow up with outpatient provider in order to prevent development into more pathologic sequelae or development of emergent problem subsequently if not properly controlled on an outpatient basis.

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