Differential Diagnosis
The patient presents with a complex set of symptoms including bilateral flank pain, hematuria, burning dysuria, fever, and nausea. Considering the patient's history and symptoms, the differential diagnoses can be categorized as follows:
Single most likely diagnosis
- Pyelonephritis: The patient's symptoms of flank pain, fever, and burning dysuria, along with the recent history of UTI treated with Augmentin, suggest a possible diagnosis of pyelonephritis. The presence of hematuria and proteinuria also supports this diagnosis.
Other Likely diagnoses
- Urinary Tract Infection (UTI): Although the patient was recently treated for UTI, the recurrence of symptoms suggests a possible persistent or recurrent infection.
- Kidney Stone: The patient's flank pain and hematuria could be indicative of a kidney stone, although the CT scan did not show any evidence of hydronephrosis.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Sepsis: Although the patient's vital signs are stable, the presence of fever, flank pain, and recent history of UTI raises the concern for possible sepsis, particularly in a patient with a history of immunodeficiency.
- Emphysematous Pyelonephritis: This is a rare but life-threatening condition that can occur in patients with diabetes, particularly those with poorly controlled blood sugar levels.
Rare diagnoses
- Renal Infarction: Although the CT scan did not show any evidence of renal infarction, this diagnosis should be considered in patients with flank pain and hematuria, particularly those with a history of hypercoagulable state.
- Renal Vasculitis: This is a rare condition that can cause flank pain, hematuria, and proteinuria, particularly in patients with a history of autoimmune disorders.
Given the patient's persistent symptoms despite being sent home on Cefdinir, and the lack of urine culture and cancelled blood cultures, it would be prudent for the patient to return to the ER for further evaluation and treatment. The patient's history of immunodeficiency and the possibility of pyelonephritis or sepsis necessitate close monitoring and prompt medical attention.