HISTORY
Patient is a 24-year-old female who was admitted through the Emergency Department to my service on ______ call. I was called at approximately 11 p.m. on the night of admission. She was admitted for pyelonephritis and right adnexal mass and nausea and vomiting. She states on Wednesday she started having right sided back pain, on Thursday she got fever up to 101.6 that had come and gone and by Thursday evening to Friday a.m. it was hard to urinate. She has a history of kidney stones. Most recently she passed one 4 months ago through Thomas Hospital ER. She was given some medicines at home and she passed the stone, so we did a CT scan on her thinking may be she had no stone. When she was brought to ER there was no evidence of stone, but she did pickup a right adnexal mass per ER report of 5 x 7 cm. She was examined and did not feel to have PID. When we got a blood work back her white count was slightly elevated but then she was noted to have a very cloudy urine with lots of white cells and this is most consistent pain with pyelonephritis. So I am not sure this lady had obstruction earlier when it is hard to urinate or went on. When I see patient she is in lot discomfort in right flank. She was surprised about the mass in her adnexa. She has already seen _____ in consultation. We discussed differential diagnosis but ______ has done this as well.
PAST MEDICAL HISTORY
Patient is a 24-year-old female who was admitted through the Emergency Department to my service on ______ call. I was called at approximately 11 p.m. on the night of admission. She was admitted for pyelonephritis and right adnexal mass and nausea and vomiting. She states on Wednesday she started having right sided back pain, on Thursday she got fever up to 101.6 that had come and gone and by Thursday evening to Friday a.m. it was hard to urinate. She has a history of kidney stones. Most recently she passed one 4 months ago through Thomas Hospital ER. She was given some medicines at home and she passed the stone, so we did a CT scan on her thinking may be she had no stone. When she was brought to ER there was no evidence of stone, but she did pickup a right adnexal mass per ER report of 5 x 7 cm. She was examined and did not feel to have PID. When we got a blood work back her white count was slightly elevated but then she was noted to have a very cloudy urine with lots of white cells and this is most consistent pain with pyelonephritis. So I am not sure this lady had obstruction earlier when it is hard to urinate or went on. When I see patient she is in lot discomfort in right flank. She was surprised about the mass in her adnexa. She has already seen _____ in consultation. We discussed differential diagnosis but ______ has done this as well.
She is allergic to penicillin from a GI standpoint. She also gets a rash with Demerol. She is on chronic medication. She has been hospitalized once for vaginal
delivery of her 3-year-old son. She also
had a bilateral tubal ligation after this for postpartum hemorrhage she was
told. She is divorced for a year. She has had no other surgeries.
FAMILY HISTORY
Mother and grandmother had questionable ovarian cancer and
there is diabetes in the family.
SOCIAL HISTORY
She has moved to this Eastern Shore Area 8 months ago.
She is divorced for a year. Her
son lives with her, 6 months, and her ex-husband for 6 months. She lives down here with her "adopted
mom" some lady met she met 2 years in Indiana and they moved down here
together. She has just taken a job 3
months ago as a manager of the Pizza Hut in Daphne. She does not smoke, does not drink. She states she is married 2 years prior.
OBJECTIVE
GENERAL: When I saw
the patient, she is complaining of lot of pain and says that she gives up, she
feels nauseated. Said even though she is
hurting and nauseated, she still want to work everyday at Pizza Hut and even
worked yesterday Friday.
ENT EXAM: She has a
dry oropharynx.
NECK: Supple. No meningeal signs.
CHEST: She has
bilateral breath sounds clear to auscultation.
CARDIAC EXAM:
Revealed a regular rate and rhythm without ectopy.
ABDOMEN: She has
positive bowel sounds. She is tender in
the right flank and her right pelvic region.
This really is making her abdomen hurt, but she admits it is mainly on
the right and mainly in her back that hurts the worst.
EXTREMITIES: No
edema.
LABORATORY DATA
As mentioned she had urinalysis from last night at 10
o'clock. Within 10 hours she has already
grown out E. coli greater than 100,000 count.
Her urinalysis last night showed 3+ blood, positive nitrates, positive
leukocytes, she has 2150 white cells with mini bacteria, white count was only
9.7 with a slight left shift. H and H
was 12.0 and 34.1 respectively. Serum
pregnancy test was negative. Multi-chem
plus, only abnormality was her potassium 3.3, her BUN and creatinine ratio was
only 1:9.
ADMISSION DIAGNOSES
1. Acute
pyelonephritis. Urine culture
obtained. She is on IV Levaquin. We are going to discontinue Bactrim that was
given in the emergeny room since she has had some nausea and vomiting.
2. Right
adnexal mass, I appreciate consult with ______ and his input.
3. Hypokalemia.
4. Nausea
and vomiting.
PLAN
Continue the IV fluids to replace the potassium. Continue antibiotics till culture and
sensitivities come back. I explain to
her this might take 2 to 3 days of hospitalization and her fever will
spike. She was told that she might be
get some fluids and go home the next day, but she is still vomiting.
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