A 2-year-old Holstein cow was examined because of a 2-month history of anorexia, decreased milk production, and a white vaginal discharge. Results of physical, laboratory, and ultrasound examinations were consistent with pyelonephritis. Through ultrasound examination, the right kidney and ureter were identified as structurally involved. Right nephrectomy was performed. Eight months after nephrectomy, the cow was clinically normal. In this cow, ultrasonography helped to determine disease severity, to direct the course of treatment, and to improve the accuracy of diagnosis and prognosis.