Differential Diagnosis for a 64-year-old Male with Suspected Pyelonephritis and Nephritis

The patient presents with a complex set of symptoms including fever, chills, right-sided CVA (cerebrovascular accident), pain, tachycardia, and dysuria. Given these symptoms, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Pyelonephritis: This is the most likely diagnosis given the symptoms of fever, chills, dysuria, and flank pain, which are classic for an upper urinary tract infection. The presence of tachycardia can also indicate a systemic infection.
• Other Likely Diagnoses
  • Sepsis: The combination of fever, chills, tachycardia, and a potential source of infection (pyelonephritis) raises the concern for sepsis, a life-threatening condition that requires immediate attention.
  • Nephrolithiasis (Kidney Stones): While not directly indicated by all symptoms, the presence of pain and dysuria could suggest kidney stones, especially if the pain is severe and colicky.
  • Urinary Tract Infection (UTI) with Complications: Given the patient's age and symptoms, a complicated UTI could be a consideration, especially if there are underlying conditions affecting the urinary tract.
• Do Not Miss Diagnoses
  • Endocarditis: Although less likely, the presence of fever, new-onset heart murmur (if present), and embolic phenomena (suggested by the right-sided CVA) could indicate endocarditis, a condition that is critical not to miss.
  • Aortic Aneurysm or Dissection: Severe, tearing pain and a recent CVA could, in rare cases, suggest an aortic pathology, which is immediately life-threatening.
  • Severe Sepsis or Septic Shock: Given the systemic symptoms, it's crucial not to miss the progression to severe sepsis or septic shock, which requires immediate intervention.
• Rare Diagnoses
  • Tuberculosis of the Urinary Tract: While rare in many populations, TB can cause chronic infections of the urinary tract, presenting with systemic symptoms like fever and weight loss, along with urinary symptoms.
  • Emphysematous Pyelonephritis: A rare but serious infection of the kidney, more common in diabetic patients, characterized by gas in the kidney tissue.

Diagnostic Plan

• Imaging: CT scan of the abdomen and pelvis to evaluate for pyelonephritis, kidney stones, or other complications. Consider a CT angiogram of the head and neck if the CVA is suspected to be of embolic origin.
• Laboratory Tests: Complete blood count (CBC), blood cultures, urine analysis, and urine culture. Consider inflammatory markers like CRP and procalcitonin if sepsis is suspected.
• Other Tests: Depending on the suspicion of other diagnoses, additional tests like echocardiography for endocarditis or aortic pathology might be necessary.

Pharmacological Plan

• Antibiotics: Empirical antibiotic therapy should be started immediately if pyelonephritis or sepsis is suspected, with coverage for common urinary pathogens.
• Pain Management: Appropriate analgesia for pain control.
• Supportive Care: Fluid resuscitation and management of vital signs as necessary.

Non-Pharmacological Plan

• Fluid Hydration: Encourage oral hydration if possible.
• Rest: Bed rest may be recommended depending on the severity of symptoms.
• Monitoring: Close monitoring of vital signs and urine output.

Emergency Room Visit

Given the severity of symptoms, including a recent CVA and signs of a potential systemic infection, yes, the patient should go to the emergency room. The combination of fever, chills, dysuria, and a new neurological deficit (CVA) suggests a serious condition that requires immediate medical attention.