C.C: fever, chills with flank pain for 2 days
P.I: This 33y/o female noted progressive fever since the afternoon of 2 days PTA.
The fever was not different between day and night. Chills, bilateral flank
soreness were also noted. She ever bought antibiotics from pharmacy to use.
The next day, fever was up to 40℃ and headache, dizziness, vomiting ×3 were
noted. She denied dysuria, frequency, or hematuria but had remarkable R’t
flank pain. Then she came to our ER for help.
She said she has ever got UTI for several times since 1998. Fever was also
complained but not higher than this time. The symptoms subsided within 2-3
days after antibiotics use , and renal echo showed normal. She denied stone
history or operation history before. She also denied alcohol use, smoking, and
any drug allergy history.
At our ER, WBC showed 11840, U/A revealed WBC numerous, and BUN/Cr
presented 6/0.8. NSAID was used for analgesic and decreasing of temperature.
Because of suspecting APN, she admitted to our ward for further treatment.
Dr Buttrey’s rewrite:
CC: 33 y/o female c/o fever and flank pain for 2 days
PI: The patient has had several episodes of UTI over the past 4 years, usually presenting with
dysuria. She has been successfully treated with antibiotics for these episodes, which were
sometimes associated with a low-grade fever. She denies previous flank pain or
hospitalization for this problem. A renal echo [Date?] was normal. She denies any known
history of kidney stones.
Two days PTA, she noted a fever that gradually increased without any particular pattern and
was eventually associated with chills. She denied dysuria, frequency, or hematuria, but she
had dull R flank pain with the initial fever which subsequently increased in severity. She took
some antibiotics on her own, but the next day the fever increased to 40OC and she had
headache, dizziness and vomiting x3. She came to the ER and was found to have a WBC
count of 11,849 and numerous WBCs on U/A. Her BUN/Cr were 6/0.8. She was then admitted
with a suspected diagnosis of APN.
Missing data: A clearer description of the more severe flank pain would be good. Commnet on
risk factors for recurrent UTI, i.e., sexual activity, poor hygiene, tampon use, or current
pregnancy. I didn’t mention the lack of smoking or alcohol use because these aren’t
particularly relevant to this disease. The drug allergy history is important in deciding what to
give her, but we don’t usually mention it specifically in the PI if its negative. (It should, of
course, appear in the appropriate section of the chart for recording allergies.)
Comments
Content:
This is a well-written history of a straightforward case. The order of reporting, i.e.,
current episode first vs. past hx of the PI first is arbitrary. Different doctors prefer
different orders. Sometimes a particular patient’s story is more amenable to a
particular order. I wrote mine in the order I did because the CC immediately
suggested APN, and giving the past hx of UTI right away increased the probability of
that dx. But there is nothing wrong with the original order!
More attention should be paid to risk factors, because we’d like to decrease this
woman’s incidence of UTIs if possible. Marked abnormalities of the collecting system
were essentially ruled out by noting the negative US, although the date that was done
is important. Her specific denial of a hx of kidney stones doesn’t eliminate that
possibility in this particular episode but makes it less likely. The quality of the severe
flank pain should be described more clearly. If she had suddenly developed very
severe colicky pain that radiated toward the inguinal area, and she was unable to find
a comfortable position, we’d more likely consider a stone with accompanying
infection. (Also, if on general appearance, she was writhing around on the bed in
obvious pain, stone would be a strong possibility.) Regardless of whether there are
structural and mechanical factors implicated in her recurrent UTIs, it’s important to
discuss with her good hygiene after sexual activity and after defecation.
English:
She ever bought antibiotics: In English, we only use ever in questions (Have you ever
had a UTI?), imperative statements (Don’t ever use “ever” like that.), and negative
declarative statements (We do not ever say that.) Note in the last example, we could
substitute “never” for “not ever.” We don’t use ever in positive declarative statements.
Instead, use words like “once,” “several times,” “many times,” or a format indicating
past action, e.g., She has bought antibiotics in the past for a UTI.
Remarkable: This
is a correct English word but is too nonspecific to describe a
symptom in the hx. What was remarkable about it?
has ever got UTI:
“Ever” is incorrect as explained above. “Got” is not normally used to
describe development of a disease. An alternative statement would be “She has had
several previous UTIs.”
Fever was also complained:
Use the preposition “of”: “Fever was complained of.”
However, a better sentence would be “She complained of fever.” Avoid a passive verb
when an active verb is easily substituted. (For a longer description of the complaint,
we use “that,” e.g., “She complained that the medicine wasn’t helping.”)
renal echo showed normal:
“The renal echo was normal”
WBC showed 11840, U/A revealed WBC numerous, and BUN/Cr presented 6/0.8: Avoid
lot of verbs. Write “WBC was 11840, BUN/Cr 6/0.8, and the U/A had numerous
WBCs.”
Because of suspecting APN:
“…suspected APN, ….” Or, “She was admitted for
suspected APN.” In English, we don’t have to put the “because” statement at the
beginning of the sentence. (In my sentence, “for” is essentially equivalent to
“because.”)
a