Level 3: Fever – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 57 y/o female who presents to urgent care saying: “I haven’t been feeling very good, and my lower abdomen has hurt for the past two days.” She complains of subjective fever but is in no acute distress.

HPI: Patient notes that 2 days ago she began to experience insidious onset lethargy, low-grade fever and lower abdominal pain. She reports that she has taken her temperature multiple times since then and it has ranged from 98.1-99.8. She describes the pain as a 4/10, sharp pain in her lower abdomen that does not radiate anywhere. She says that the pain is typically worse when she feels the need to urinate and she states that she “feels like I have to go all the time” for the past 2 days. She also notes experiencing a burning pain while she is urinating. She denies experiencing prior symptoms. She denies any recent vaginal discharge or bleeding, but states that her urine has “looked kinda cloudy.” She reports that she is sexually active, but that she and her boyfriend always use condoms. Denies any history of STIs or partners with STIs.

PMH: Appendectomy at 23 years old, G1P1, caesarian section at 28 years old, Laparoscopic Cholecystectomy at 43 years old, Diagnosed with Type 2 Diabetes Mellitus at 47 years old, treated with diet, exercise, and Metformin, 850 mg PO BID.

SH: noncontributory

FMH: Father alive at 85 years old with HTN and type 2 Diabetes mellitus, Mother deceased at 63 from Colon cancer, No siblings

General – No recent weight changes. Has felt tired and lethargic for the past two days.
Abdomen – Experiences daily bowel movements. Denies constipation, diarrhea, or melena.
GU – See HPI.
Endocrine – Reports that her last HbA1C was taken 3 days ago and was 9%. She states that she sometimes forgets to take her Metformin and that she has not kept an eye on her diet in the last 5 months.

VS – Height 5’4’’, Weight 200lbs, BMI 34.3, HR 92, BP 136/88, RR 16, Temperature 99.6
Abdomen – Bowel sounds active in all 4 quadrants. Mild tenderness in suprapubic region to deep palpation. No other abdominal tenderness to light or deep palpation. Liver and spleen not palpable with negative Murphy sign. No CVA tenderness.
GU – External genitalia are unremarkable. No cervical motion tenderness or evidence of discharge. Both ovaries are palpable on bimanual examination with no masses present.

Non-fasting Glucose- 139mg/dL

Hemoglobin 13.0 mg/dl
Hct- 39%
RBCs- 4.9 million/mcl
WBCs- 13.2 million/mcl
Neutrophils- 88%

Urine pH- 5
Blood- Negative
Leukocyte Esterase- Positive
Nitrites- Positive
WBCs- 25-50/hpf

Urine Culture- >100,000 colonies/mL of E. Coli