S:

RF is a 26 yo female with chief complaint of right chest pain. She describes 5/10 continuous pain and chest tightness that began yesterday and radiates to the back. This is the first occurrence. Admits anorexia, pain with inspiration. Denies shortness of breath, cough, wheezing, fever, chills, weight loss, oral contraceptive use. Patient states she underwent a work up on Wednesday at Harlem Hospital, where she works, for complaint of RUQ abdominal pain accompanied by fever and chills. Per patient, ultrasound of gallbladder was unremarkable, but UA showed RBCs and WBCs. She was diagnosed with pyelonephritis and prescribed Ciprofloxacin 1000mg ER PO q24h x 7d but has not started them yet.

PMH: Mitral Valve Prolapse

PSH: Denies

Allergies: NKDA

Medications: Tylenol (Acetaminophen) 1g q6h prn

FHx: Non-contributory

SHx: Denies EtOH, Tobacco Use, Illicit Drug Use

O:

T 37.1C | BP 98/63mmHg | P 108 BPM, regular | RR 16 breaths/min, unlabored | O2 100% RA

H 66in | W 130 lb. | BMI 21.0

Gen: Slender female, neatly groomed, looks her stated age of 26 years. Alert and cooperative and in no apparent distress.

CV: RRR. S1 and S2 are normal. Mid-systolic click. No S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Abd: Flat, symmetrical. No scars, striae, caput medusa. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. Non-tender to light and deep palpation throughout. + Right CVAT. No guarding, rebound, organomegaly.

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis, atrophy in right or left lower extremities. Negative Homans sign bilaterally. No palpable cords.

A:

26 yo female with right sided chest pain, + right CVAT, and recent diagnosis of pyelonephritis for which she has not yet started her medication. Likely right pyelonephritis.

Differential Diagnosis:

1. Pulmonary Embolism
2. Myocardial Infarction
3. Right Pyelonephritis
4. Pericarditis
5. Pneumonia

P:

Labs:

• Qualitative Beta-hCG with Reflex
• CBC, BMP
• D-Dimer, R/O: PE
• Troponin, R/O: MI
• U/A, Urine Culture

Imaging/Tests:

• EKG
• CXR

Likely Right Pyelonephritis:

• Start 1L Normal Saline IV
• Pending U/A, Urine Culture results. If +, plan to discharge with Ciprofloxacin 1000mg ER PO q24h x 7d

Mitral Valve Prolapse:

• Patient is asymptomatic at this time. Advised to follow up with her cardiologist if she experiences new symptoms.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

Pulmonary Embolism                                                 Pulmonary Embolism

Myocardial Infarction                                                 Myocardial Infarction

Aortic Dissection                                                         Right Pyelonephritis

Right Pyelonephritis                                                    Pericarditis

Unstable Angina                                                         Pneumonia

Pericarditis

Mitral Valve Prolapse

Pneumonia

Esophagitis

GERD

Gastritis

PUD

Pancreatitis

Cholecystitis

Hepatitis

Musculoskeletal Pain

Panic Disorder

Illness Anxiety Disorder

Pott’s Disease