Physician's Assistant

Patient Details

Sdec (55 days ago 13:46)

Sdec Tue 10 February 2026 13:46

Last Modified: 55 days ago

MRN:

Content:

Presenting Complaint:
Left loin pain with dysuria and vomiting

Past Medical History
• Previous urinary tract infections
• Chronic pain (on amitriptyline and codeine)
• Early pregnancy (recently confirmed)

Diagnosis:
Left-sided pyelonephritis in early pregnancy

I had the pleasure of meeting Michelle Duffy in Same Day Emergency Care today.

Ms Duffy is a 32-year-old lady who attended with a one-week history of dysuria, urinary frequency and right-sided loin pain. She initially presented to her GP last Thursday with suspected urinary tract infection and was started on co-amoxiclav. However, she has been intolerant of this antibiotic, experiencing significant vomiting. She has had previous urinary tract infections and reports that this episode feels similar to previous infections she has experienced.

The pain is located in the right loin and has been constant over recent days, exacerbated by movement. She has experienced high fevers at home with rigors, particularly last night. She has been unable to sleep for approximately three nights due to her symptoms. She has recently discovered she is pregnant, which came as a surprise to her.

She lives at home with her three children. She is currently on amitriptyline for chronic pain and takes codeine 15mg as needed.

On examination, she was alert and comfortable at rest. Temperature 37.3°C, BP 115/90, HR 109, RR 16, saturations 98% on room air. She had significant tenderness over the right renal angle with percussion tenderness. Abdominal examination revealed some right-sided tenderness but no peritonism. The left side was less tender. Chest examination was unremarkable.

Investigations:
Urine MC&S: Awaited
Urine dip: No blood, leucocytes present
Venous blood gas: pH 7.38, base excess -0.8, lactate 1.1 (normal)
Bone profile: Normal
U&Es: Normal with creatinine at baseline
LFTs: ALT 46, AST 38 (mildly elevated but otherwise normal)
CRP: 8
Full blood count: Awaited (blue top sent but not yet processed)

Plan:
1. Discharge on cephalexin (safe in pregnancy) as alternative antibiotic for pyelonephritis, having been intolerant of co-amoxiclav
2. Increase codeine to 30mg for analgesia (safe in early pregnancy)
3. Prescribe paracetamol for home use
4. Arrange outpatient ultrasound scan of renal tract to exclude renal calculus (though seems unlikely given absence of haematuria on urine dip)
5. Safety-net advice to return if symptoms worsen, persistent vomiting, or increasing pain
6. GP follow-up for review of urine culture results and clinical progress
7. Continue with antenatal care as arranged with universal clearance team

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

• Consider more thorough antenatal history - gestation not documented, booking status unclear, and patient emotional response to pregnancy noted but not fully explored
• Missed opportunity for safety-netting around pregnancy-specific complications - should have explicitly discussed warning signs of pregnancy complications and when to seek urgent review
• Examination findings could be more systematic - no documentation of cardiovascular or respiratory examination beyond 'chest unremarkable'
• Could have explored social support more thoroughly given patient's comment about three children at home and lack of partner mentioned - important for follow-up compliance
• Consider documenting discussion about alcohol and smoking status in pregnancy
• Pain score not documented - useful for baseline and monitoring response to treatment
• Could have been clearer about expected timeline for symptom improvement and when to escalate if not improving
• Consider referral to antenatal team given infection in pregnancy rather than just continuing with existing arrangement