A 45-year-old female presented with vomiting, dizziness, and urinary symptoms. On examination, she had costovertebral angle tenderness and tenderness of the right kidney. A urinary pregnancy test was positive. The likely diagnosis is pyelonephritis (upper urinary tract infection) given her urinary symptoms and tenderness. Differential diagnoses include kidney stones but these typically cause intermittent pain rather than constant pain. The plan is to hospitalize the patient, start IV fluids and antibiotics, obtain diagnostic tests, and provide patient education.
A 45-year-old female presented with vomiting, dizziness, and urinary symptoms. On examination, she had costovertebral angle tenderness and tenderness of the right kidney. A urinary pregnancy test was positive. The likely diagnosis is pyelonephritis (upper urinary tract infection) given her urinary symptoms and tenderness. Differential diagnoses include kidney stones but these typically cause intermittent pain rather than constant pain. The plan is to hospitalize the patient, start IV fluids and antibiotics, obtain diagnostic tests, and provide patient education.
A 45-year-old female presented with vomiting, dizziness, and urinary symptoms. On examination, she had costovertebral angle tenderness and tenderness of the right kidney. A urinary pregnancy test was positive. The likely diagnosis is pyelonephritis (upper urinary tract infection) given her urinary symptoms and tenderness. Differential diagnoses include kidney stones but these typically cause intermittent pain rather than constant pain. The plan is to hospitalize the patient, start IV fluids and antibiotics, obtain diagnostic tests, and provide patient education.
A 45-year-old female presented with vomiting, dizziness, and urinary symptoms. On examination, she had costovertebral angle tenderness and tenderness of the right kidney. A urinary pregnancy test was positive. The likely diagnosis is pyelonephritis (upper urinary tract infection) given her urinary symptoms and tenderness. Differential diagnoses include kidney stones but these typically cause intermittent pain rather than constant pain. The plan is to hospitalize the patient, start IV fluids and antibiotics, obtain diagnostic tests, and provide patient education.
20 Patient Name: R.C. Date: 02/25/20 Time: 9:30am Faculty Evaluator: Dr. Biermann Small Group Leader: Dr. LaCombe Medical Student name: Nicole Cantellops Subjective Chief Complaint “vomiting and dizziness”
History of Present Illness (include opening statement with Patient ID)
A 45-year-old female with a significant PMHx of UTI’s presented with severe vomiting and dizziness. This symptom started five days ago accompanied by feeling warm, achiness, and symptoms like the flu. This symptom got worst yesterday, and she started having chills and feeling shaky. Patient reported having a sharp pain on the right side of her back well localized. Stated that moving around made it worst and that the pain was constant and rated it a 7 out of 10 on the scale, but it didn’t wake her up at night. Patient also stated having a UTI seven days ago but drank cranberry and went away. She confirmed having two to three UTI’s in the last year.
Past History Chronic Medical Illnesses (include duration of each illness): No chronic illnesses
Mental Health Issues (include duration of each illness):
No hospitalizations Surgical History (include dates, indications, types of surgery, complications): No surgical history Ob-Gyne History (gravida/para status, last menstrual period, contraceptive use, condoms): Patient reported having regular menstrual periods, but her last menstrual period was 10 weeks ago. Patient took OCP’s but stopped them two months ago Health Care Maintenance (include dates of last PCP visit, age-specific screening tests and immunizations): Tetanus vaccine a couple of years ago
Medications (include name, dose, route and frequency; also add duration if pertinent to case): Advil 400 mg 3 times a day but stopped 3 days ago Sprintex; OCP but stopped 2 months ago
Drug / Food Allergies
Allergic to sulfa drugs, gives her hives No food allergies
Social History Patient has no specific diet, doesn’t exercise, drinks two to three beers on the weekends. Patient smoked weed, smokes half a pack a day for 15 years. Patient has no pets, hasn’t traveled. Patient states living in a shelter and clean houses as her occupation. Family History Patient doesn’t know her family history since she was adopted
Review of Systems Patient denied: changes in vision, blurry or double vision, SOB, cough, chest pain, palpitations, changes in bowel movements, swelling, weight loss or gain, tingling or numbness, and no blood in urine. Patient had nausea and vomiting, dizziness when standing up, dysuria, fatigue, increased frequency in urination and a dark colored urine.
Objective Physical Exam (only include applicable exams) Vital Signs & Body Measurements: T 102.5 ⁰ F BP110/74 mmHg RR 16 bpm HR94 bpm Wt116 lbs Ht 5 ft,6 in General survey: Patient didn’t have any respiratory distress. Patient was well groomed and cooperative. HEENT: Patient had pink palpebral conjunctiva and dry mucous membranes Thorax/Lungs: Normal vesicular sound was heard with no wheezes, rhonchi or crackles CV: Normal S1/S2 was heard with no gallops, rubs or murmurs. Patient has tachycardia. Abd/Rectal: On the right side upon deep palpating the kidney was tender, upon auscultation there were no bruits heard on the renal arteries. Patient had costovertebral angle tenderness on the right side. Genitourinary: A pregnancy test was taken, and it was positive. No inguinal adenopathy. External genitalia were pink without any lesions, masses or erythema. Vaginal wall was smooth with any lesions or masses. There was a scant milky white vaginal discharge, also a bluish discoloration of the vaginal mucosa. Cervix appeared bluish and cyanotic. There was softening of the uterine isthmus and enlargement of the uterus. No adnexal masses felt. STI test was done
Office testing: include results of pregnancy test, strep test, EKG, Xrays done in the office.
Assessment Case Summary A 45-year-old female with a significant PMHx of UTI’s presented with severe vomiting and dizziness. This symptom started five days ago accompanied by feeling warm, achiness, and symptoms like the flu. Patient had a tender CVA and tenderness upon deep palpation of the right kidney. Patient also had bluish discoloration of vaginal mucosa, cyanotic bluish appearance of the cervix and a scant milky white vaginal discharge. Also had uterus enlargement and softening of the uterine isthmus. Patient tested positive on pregnancy test.
Problem List 1. Vomiting and dizziness 2. Dysuria and dark colored urine 3. CVA tenderness 4. previous UTI’s
* Differential Diagnosis (include supporting evidence for and against diagnosis)
1. Kidney stones because of the CVA tenderness, but discard because the pain for kidney stones is more intermittent and patient had a constant pain 2. Ectopic pregnancy, check with ultrasound to discard or with Beta-HCG test
2. Therapeutic Plan 1. Hospitalize patient 2. IV fluids and antibiotics 3. Change to oral antibiotics when patient is clinically well for 14 days 4. Ibuprofen for the pain on her right flank
3. Patient Education 1. Increase fluid intake 2. Urinate before and after sexual intercourse 3. Use protection in sexual intercourse 4. Take all antibiotics 5. When going to the bathroom wipe herself from the front to the back 6. Counsel her on getting a social worker for her social status right now
4. Follow up 1. 1 week after discharge
Signature Print Name, Medical School Level (MS II) and UMHS If the patient presents with multiple unrelated diagnoses (issues), include a likely diagnosis and differential diagnosis discussion for each issue separately. You may, however, list the plan all together under a single plan section.
