JK, a 37-year-old mother of two, came to the clinic today (09/09/2017) with complaints of right-sided flank discomfort. She also has a fever, loss of appetite, nausea, and vomiting, which she says started three days ago. She says her suffering as excruciatingly severe. While over-the-counter acetaminophen has provided brief comfort, nothing is alleviating the agony. According to her, the queasy sensation worsens shortly after eating or drinking. Despite this, she can tolerate toast, apple juice, and water. She denies any injury to her flanks. OTC Acetaminophen for relieving the groin pain
One a day vitamin pills as she plans to become pregnant in a near future
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Family History
The mother died of kidney failure, and the older brother had the gall bladder removed five years ago. Father alive and healthy.
Social History
A mother of three, working, and rarely smoke, drinks occasionally. Separated with husband four years ago. She has a boyfriend, where they do have casual sex regularly
ROS
General
Denies weight change, fatigue, fever, chills, night sweats, and energy level
Cardiovascular
Denies chest pain, palpitations, PND, orthopnea, and edema
Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles
Respiratory
Denies coughing, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
Eyes
Does not use corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Experiences abdominal pain. No constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ears
Denies ear pain, hearing loss, ringing in ears, and discharge
Genitourinary/Gynecological
Experiencing increased urge to urinate. Denies burning sensation, change in color of urine, past STDs, menstrual complaints, vaginal discharge, and pregnancy.
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Musculoskeletal
Denies back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis
Breast
Rejects SBE, lumps, bumps, or changes Neurological
Denies syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells
Heme/Lymph/Endo
Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric
Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx
OBJECTIVE
Weight 130 pounds BMI 21.0 Temp 101.0°F BP 125/85
Height 5' 6" Pulse 114 bpm Resp 14 breaths
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Shy in revealing her sexual and marital history.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. The pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
The bladder is nondistended; CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. The cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, the cervix is firm. No CMT. The uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable; No evidence of hemorrhoids, fissures, bleeding, or masse. Costovertebral angle tenderness
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urine culture-pending
Special Tests
Leukocyte esterase test
Nitrite test
Diagnosis
Differential diagnoses
Endometritis
Acute cystitis
Cervicitis
Urethritis
Ovarian cyst
Appendicitis
Ectopic pregnancy
Pancreatitis
Final diagnosis
Pyelonephritis
Evidence
symptoms such as worsening right flank pain, fever, nausea, and vomiting
Risk factors such as sexual behavior and familial predisposition
PLAN including education
Plan:
Further testing
Urinalysis
Urine culture
Medication
Ciprofloxacin (250 mg PO q12hr for 3 days)
Quinapril (5 mg twice daily)
Education
Discuss preventive measures
Advising patient on the signs and symptoms of the infection
Nonmedication treatments
Advice on hygienic and sexual practices such as
Drinking plenty of fluids
Avoiding irritants such as spray
Urinating after sex to flush out pathogens
Wiping from front to back to prevent the spread of fecal bacteria to the urinary tract
Follow-up
Monitoring blood pressure to offset vulnerability
