Urinary Tract Infection in infant

HISTORY:

‍Urinary symptomsFever for ‍ ‍hoursdays

‍fever, up to ‍°, over ‍ ‍hoursdays

‍irritability

‍foul-smelling urine

‍hematuria

‍cloudy urine

‍abdominal pain

‍flank pain

‍urinary frequency

‍urinary urgency

‍dysuria

‍enuresis

‍poor feeding

‍vomiting

‍diarrhea

‍lethargy

‍decreased activity

‍decreased fluid intake

‍decreased urine output

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Mouth: ‍normal

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Chest: ‍tenderness on ‍rightleft ‍

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Genital: ‍normal, testicles ‍normal, penis ‍normal, Tanner stage ‍

Extremities: ‍normal, ‍normal pulses, cap refill ‍< 3 sec> 3 sec

Skin: ‍no rash

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM



ASSESSMENT:

‍Urinary tract infection ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Urinalysis

- Urine culture

- Blood work: ‍CBC, ‍CRP

- Renal ultrasound

- Voiding cystourethrogram

- DMSA scan

- ‍Antibiotics

- ‍Acetaminophen

- ‍Ibuprofen

- Encourage fluids

- Avoid constipation

- Avoid bubble baths

- Avoid scented soaps

- Avoid holding urine

- Referral to pediatrician

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop