R.E.’S Case Study

QUESTION

R.E. is a 34-year-old African American female who came to the clinic with complaints of right-side lower back pain and painful urination for two days. The patient also presented with fever, chills, nausea, abdominal discomfort, and lower abdominal pains. She reports a strong urge to urinate, urinating more times than usual. She describes the color of the urine as cloudy urine. The patient said the pain is rated 5/10 and has increased over time. She reports that she has been using Tylenol to relieve the pain at home, which did not help with the pain. The patient reports that she is sexually active with her partner. She denies vomiting, hematuria, recent urinary tract infection, or recent incontinence.

The physical exam shows a temperature of 102.2ºF (39.0ºC), blood pressure of 120/60, pulse of 110, respiratory rate of 18, and right-sided costovertebral angle tenderness to percussion. Dipstick urinalysis is positive for leukocytes, nitrites, and blood.

Subjective: What details did the patient provide regarding the personal and medical history?

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

ANSWER

Subjective

The patient, R.E., provided details regarding her personal and medical history. She reported symptoms of right-side lower back pain, painful urination, fever, chills, nausea, abdominal discomfort, and lower abdominal pains. She also mentioned a strong urge to urinate and cloudy urine. R.E. disclosed that she is sexually active with her partner and denied vomiting, hematuria, recent urinary tract infection, or recent incontinence.

Objective

During the physical assessment, R.E. had a temperature of 102.2ºF (39.0ºC), blood pressure of 120/60, pulse of 110, and respiratory rate of 18. One significant finding was the presence of right-sided costovertebral angle tenderness to percussion, indicating possible kidney involvement. The dipstick urinalysis showed positive results for leukocytes, nitrites, and blood, further suggesting a urinary tract infection (UTI). These findings, along with the patient’s reported symptoms, indicated potential morbidities such as pyelonephritis or a complicated UTI. Psychosocially, R.E. mentioned her sexual activity, which could impact her risk for certain infections.

Assessment

Based on the patient’s history, symptoms, and physical exam findings, three differential diagnoses include:
1. Acute pyelonephritis (ICD-10: N10) – This is a higher priority diagnosis due to the presence of fever, chills, costovertebral angle tenderness, and positive urinalysis results indicating an upper urinary tract infection.
2. Complicated urinary tract infection (ICD-10: N39.0) – Given the severity of symptoms and potential risk factors, such as sexual activity, this diagnosis is also highly plausible.
3. Kidney stone (ICD-10: N20.0) – Although less likely based on the clinical presentation, the presence of right-sided back pain could be associated with a kidney stone.

The primary diagnosis is acute pyelonephritis because it aligns with the patient’s symptoms, positive physical exam findings, and urinalysis results. The presence of fever, chills, and costovertebral angle tenderness indicate kidney involvement, suggesting an upper urinary tract infection.

Plan

To confirm the diagnosis and assess for complications, the plan includes the following diagnostics: a urine culture to identify the causative organism and determine antibiotic susceptibility, a complete blood count (CBC) to assess for systemic infection, and a renal ultrasound to evaluate kidney anatomy and rule out any obstructive causes.

For treatment and management, the plan involves initiating antibiotic therapy, such as a fluoroquinolone or third-generation cephalosporin, based on local susceptibility patterns. Adequate hydration is crucial to promote urine flow and flush out the infection. Non-pharmacologic measures include providing comfort measures for pain relief, such as heating pads and analgesics like acetaminophen. Patient education regarding the importance of completing the antibiotic course, maintaining good hygiene, and preventive measures for future UTIs will be provided.

Follow-up parameters include monitoring the patient’s response to treatment through regular temperature checks, assessing for resolution of symptoms, and follow-up urine culture to ensure eradication of the infection.

Reflection notes

The “aha” moment during this evaluation was recognizing the significance of the costovertebral angle tenderness, which pointed towards pyelonephritis as a likely diagnosis. In a similar patient evaluation, I would consider obtaining a urine culture earlier to identify the causative organism and guide antibiotic selection. Additionally, I would aim to gather more detailed sexual history to assess for other potential risk factors and discuss safe sexual practices with the patient. Overall, this case highlighted the importance of thorough assessment and considering both common and less common diagnoses to provide appropriate care.