Patient card and observation

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

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