The case presents a diagnosis of a patient suffering from Pyelonephritis. The Ihuman report reflects the condition of the patient in regard to her medical history. It helps in determining her case analysis and the report that results present.
Below is the Ihuman Case Study on Christine Smith
Christine Smith iHuman Case: 5’6” 130#
What is the CC in this case study? Flank Pain.
This is a 33-year-old female who presents complaining of a worsening right flank pain x 2 days. She also reports a fever of 101, nausea and vomiting. She has a history of three previous UTIs. She is sexually active and referred not using protection. Upon physical examination she shows tachycardia and a positive right CVA tenderness.
What are important questions to ask the patient to formulate the history of present illness and what did the patient tell you?
How can I help you today?
Any other symptoms or concerns?
Consideration of present, past medical history, social and family Hx, and risk factors associated to the chief complain are essential elements to consider when obtaining this patient’s information. Important questions to ask about the pain include:
Where the pain is located?
When did the flank pain start?
What make the pain better and what makes it worse?
What does your flank pain feel like?
Where more precisely is your flank pain?
Rate the pain in a scale of 0-10. Where O indicates no pain and 10 indicates the worse pain.
Does the pain radiates or is confined to the same spot?
Do you have other symptoms related to the pain?
Do you feel pain when urinating?
Is there blood in your urine?
When did your fever start?
How high was your fever?
Are you having any problems with your periods?
Is your period late?
What components of the physical exam are important to review in this case?
In this case study is important to focus on the gastrointestinal, genitourinary/renal, and reproductive systems due to the reports of nausea and vomiting, fever, hx of UTIs, right flank pain, and in presence of a sexually active, multipara, premenopausal woman
What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
Positive findings included fever, nausea, vomiting, and right flank pain. Physical examination revealed a temperature of 101, a heart rate of 114, a blood pressure of 120/60, and a positive right CVA tenderness. Abnormal lab findings included a CBC/diff showing leukocytosis with shift to the left, a UA showing pyuria and bacteriuria, and gram negative rods seen on UA microscopy and culture (I-Human, n.d.).
Negative findings included no lower urinary tract symptoms. The blood cultures and UA pregnancy (HCG) testing were negative. The CT of the abdomen and pelvis was negative for evidence of renal obstruction, ectopic gestation, or tuboovarian pathology, and renal/periphrenic abscess (I-Human, n.d.).
Which differential diagnosis is to be considered with this case study?
1-Pyelonephritis: Causes right flank pain and CVA tenderness, it is often associated with fever, nausea, and vomiting. Lower urinary symptoms may or may not be present (Cash & Glass, 2014).
2- Pancreatitis, acute: This should be considered in this multipara patient taking oral contraceptive pills and presenting with abdominal/back pain associated with N/V, fever, and tachycardia.
3- Nephrolithiasis: This should be considered since it may be associated with severe flank pain, with radiation towards the groin area, nausea, and vomiting.
4- Ectopic pregnancy: This should be considered when a sexually active, premenopausal woman presents with acute abdominal pain. A negative (HCG) will ruled it out.
5- Appendicitis: This should be considered because of the patient’s report of N/V, and fever.
What was your final diagnosis?
The Final diagnosis was: Pyelonephritis: This diagnosis was considered and confirmed by the patient’s past medical history, risk factors, signs, symptoms, and laboratory results.
Pyelonephritis Common Complaints include:Shaking, chills, and fever, flank pain or tenderness, urinary frequency or urgency, CVA tenderness, and/or guarding (Cash & Glass, 2014).
This is a young sexually active female with a past history of three UTIs, the most recent one month ago, presenting with worsening right flank pain for two days, fever, nausea and vomiting. Upon physical exam there is a positive right CVA tenderness, fever of 101, and tachycardia (HR: 114). Laboratory results showed bacteriuria and nitrite positive on urinalysis along with a positive urine culture (I-Human, n.d.).
2- Pancreatitis: was ruled out by a normal limits serum lipase result (I-Human, n.d.).
3- Nephrolithiasis was ruled out by a CT of the abdomen negative for evidence of renal obstruction, and renal/periphrenic abscess (I-Human, n.d.).
4- Ectopic pregnancy: was ruled out by a urine pregnancy (HCG) test negative (I-Human, n.d.).
5- Appendicitis: was ruled out by the CT of the abdomen that showed a normal appendix (I-Human, n.d.).
References:
Cash, J. C. & Glass, Ch. A. (2014). Family Practice Guidelines, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo...
I-Human. (n.d.). Case Player: Christine Smith (V3). Retrieved from: https://app.i-
human.com/player?authToken=xFbJPfhiL...
PMH:
Current or past medical problems you have had?
Any previous medical, surgical, or dental procedures?
FHX:
Tell me about the health of your grandparents, parents & children SHX: Are you sexually active?
Allergies: none
Meds: ortho tricyclin 28, Tylenol
ROS:
Do you have any problems with fatigue, difficulty sleeping, intentional weight lsos or fan, vevers, or night sweats?
Do you have any problem with itchy scalp, skin changes, moles, thinning hair,or brittle nails
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