Nirali Desai

Name: S.Y.
Sex: Female
Age: 25
Race: White
Source of information: Self (patient)
CC: back hurts really bad x 24 hours
HPI: Patient S.Y. is a 25-year-old female reporting low back pain
accompanied with nausea, chills, and increased urinary frequency. Pt.
describes pain as a dull throb. She has reported taking ibuprofen for
relief with no success and reports no aggravating symptoms. Patient
states that she was watching a movie at onset and it has progressively
gotten worse. She reports that the pain started at a 5/10 and is
currently, a 7 or 8 out of 10.
Pertinent ROS:
Gen: pt. admits to fatigue, chills, and fever. Pt. denies HIV and
lymphadenopathy
GI: pt. admits to nausea; denies vomiting, hematemesis, dysphasia,
hernia, hemorrhoids, pancreatitis, gallbladder disease, abdominal pain,
diarrhea, or constipation
GU: patient admits to pain with urination, dysuria, hesitancy, CVA
tenderness, had a UTI a few months ago. Pt. denies flank pain or
stones, urethral discharge, genital lesions, STDs
MS: Pt. denies arthritis, joint pain, muscle cramps, stiffness, or swelling
PMH:
Allergies: no known allergies
Hospitalizations: none
Immunizations: self-reports up to date
Illnesses: none
Surgery/trauma: none
Oral medications: birth control and multivitamin, when remembered
Reproductive: current relationship; not married; no children
Youth illnesses: no serious illnesses
FH:
Father: 60 and A&W
Mother: 64 and A&W
Siblings: 1 sister-30-A&W
SH:

Pt. is a 25-year-old graduate student. Exercises at least one hour/day

and denies drug use or smoking, but admits to drinking 1 beer/week.
Currently, in a relationship and uses only birth control pills for
protection and has sex 3-4 times/week.
Assessment (DDx):
1. Pyelonephritis-pt reports costovertebral angle tenderness over renal
area, fever, and nausea over a 24-hour period. Common in young
females.
2. Pelvic inflammatory disease: pt reports high sexual activity during
the week and low back pain with fever and chills. Also, common in
young females.
3. Cystitis: pt reports dysuria and urinary urgency and frequency. CVA
tenderness is reported; sometimes accompanied with flank pain.
Plan:
Diagnostic: urinalysis and urine culture
Therapeutic: Rx for antibiotics (fluoroquinolones, cephalosporins, or
sulfonamides)
Pt education: advise pt to void urine immediately after sex and
postpone sexual activity until resolution; increase fluid intake to 8
glasses of water/day to maintain bladder hygiene
References
Medscape (Iphone app)
Epocrates (Iphone app)