Mary is a 19-year-old white female presenting to the pediatric clinic. She comes to the clinic with the complaint of bilateral lower back pain, abdominal pain, urgency with urination, elevated heart rate (HR), chills, and dysuria. She had a urinary tract infection (UTI) last week and states they usually go away. The UTI symptoms, started two days ago which included back pain and tenderness to her right flank. She denies any gastrointestinal symptoms, concern for pregnancy, need for sexually transmitted infections testing, or trauma/injury to her back. Mary states she is not sure what has caused these sudden urination problems.
Past Medical History
Mary is up to date on all of her immunizations, including the flu vaccination prior to starting college this year. Mary has a negative medical and surgical history. She reports heavy regular monthly menses. She denies any food allergy; however, she has a penicillin drug allergy. Mary denies taking any medications.
Development and Growth History
Mary reports a normal growth pattern during her life. Last menstrual period was three days prior to arrival to the clinic.
Family and Social History
Mary's mother has a history of breast cancer, and her maternal grandmother has a history of pancreatic cancer. Mary has two brothers and a sister. Mary lives in a college dormitory in a large metropolitan area. She is not involved in college extracurricular activities. Mary drinks alcohol socially – about two to three drinks per weekend – and uses recreational marijuana.
Mary appears well-nourished and well-tolerated. Mary reports eating a variety of foods daily.
Physical Assessment Findings
General appearance: Mary is a 19-year-old white female who appears well-developed and well-nourished. She comes to the clinic today in no apparent distress. She is awake, alert, and oriented to person, place, and time. She appears mildly uncomfortable. She is cooperative and appropriately responsive to questions.
Vital signs: Temp: 99.0° F. Height: 65.50 in. Weight: 154.00 lbs. HR: 80, RR: 18. BP: 106/78. O2 Saturation: 96. Body mass index: 25.23.
Normocephalic, round, symmetrical, hair evenly distributed and thick; conjunctiva clear; sclera appears white bilaterally; equal ocular movement; pupils equal round and reactive to light; auricles symmetrical, mobile, firm, and non-tender; tympanic membranes pearly gray with normal cone of light, no tympanic membrane inflammation; lips pink; teeth white and discoloration noted; tongue pink and dry as well as the oral mucosa; negative for sinusitis, rhinitis; uvula midline; symmetric palate; neck supple; no lymphadenopathy; thyroid not palpable; trachea midline; and full range of motion of neck.
Integumentary. Skin warm and dry to touch without lesions and/or cuts and brisk skin turgor.
Respiratory. Respirations even and non-labored. Breath sounds clear bilaterally upon auscultation. No wheezing, rhonchi, rales or airway compromise noted.
Cardiovascular. S1 and S2 sounds noted. Regular, rate, and rhythm noted without any murmurs and no visible pulsations on aortic and pulmonic areas. Capillary refill brisk.
Abdomen. Soft, suprapubic tenderness. Bowel sounds present and normal all quadrants, rounded abdomen, normal appearance, no abdominal bruit, and no ascites.
Neurological/Psychiatric. Deep tendon reflexes 2+/4 in all extremities. Negative Romberg. Oriented to person, place, and time. Speech and cranial nerves intact. 5/5 strength upper and lower extremities, bilaterally. Makes appropriate eye contact and conversation has normal mood and affect.
Musculoskeletal. No abnormalities or laxity noted in any of her joints. Ambulates with a steady gait.
Genitourinary. Right costovertebral angle tenderness.
Pediatr Nurs. 2020;46(4):202-203. © 2020 Jannetti Publications, Inc.