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Difficulty: EasyDisposition and Care Setting Transitions

A 28-year-old woman is evaluated in the emergency department for a 2-day history of right-sided back pain, fever, and chills. She also reports severe nausea and has vomited four times over the past 6 hours. She has no significant past medical history and takes no daily medications.

Temperature is 39.0°C (102.2°F), blood pressure is 115/75 mmHg, pulse is 112/min, and respirations are 18/min. Physical examination reveals marked right-sided costovertebral angle tenderness. The patient appears flushed and actively vomits a small amount of bilious fluid during the examination.

Laboratory results:
Leukocyte count: 16,500/mm³
Serum creatinine: 0.8 mg/dL
Urine pregnancy test: Negative
Urinalysis: Positive for nitrites and leukocyte esterase; >50 WBCs/hpf

The patient is given 1 L of intravenous normal saline, intravenous ceftriaxone, and intravenous ondansetron. Two hours later, her temperature is 38.3°C (100.9°F), pulse is 95/min, and blood pressure is 118/78 mmHg. The nurse provides her with a small cup of water, which she immediately vomits.

Based on these findings, which of the following is the most appropriate disposition for this patient?

  1. Admission to the general medical wardAnswer
  2. B
    Discharge home with a prescription for oral ciprofloxacin
  3. C
    Discharge home with arrangements for daily outpatient intravenous ceftriaxone
  4. D
    Admission to the intensive care unit
  5. E
    Transfer to a skilled nursing facility

Answer

Admission to the general medical ward
This patient has acute pyelonephritis and demonstrates persistent intractable vomiting despite the administration of intravenous antiemetics. While many younger, healthy patients with pyelonephritis can be safely treated in the outpatient setting, clear indications for inpatient admission include an inability to tolerate oral hydration or medications, hemodynamic instability, severe pain, or complications such as urinary obstruction. Because she failed an oral fluid challenge, she requires ongoing intravenous maintenance fluids and intravenous antibiotics to prevent severe hypovolemia and ensure adequate treatment. This requires an inpatient admission to a general medical ward.

Step-by-Step Solution

1
Diagnose the patient's acute condition based on clinical and laboratory findings.
The patient has acute pyelonephritis, supported by fever, costovertebral angle tenderness, leukocytosis, and a positive urinalysis.
Establishing the correct infectious diagnosis determines the baseline treatment requirements (antibiotics and hydration).
2
Assess the patient's severity and ability to tolerate outpatient treatment.
The patient is hemodynamically stable but has intractable vomiting, failing a direct oral challenge in the emergency department.
Disposition decisions for pyelonephritis hinge largely on the patient's ability to maintain hydration and absorb oral medications at home.
3
Determine the most appropriate care setting based on the assessment.
Admission to the general medical ward is required for continuous intravenous hydration, intravenous antibiotics, and close monitoring.
An inability to tolerate oral intake mandates an inpatient level of care until the patient improves and can be safely transitioned to oral therapy.

Key Concept

Hospital admission criteria for acute pyelonephritis including intractable vomiting and inability to tolerate oral hydration.
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Topics

Disposition and Care Setting Transitions

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