Case: headache, back pain, and fever

A 30-year-old woman presents to the emergency department with a chief complaint of headache, back pain, and fever. A week and a half ago, she had some vaginal itching and discharge with little pain, which she thought was a yeast infection so she used Monistat. But after five days with no improvement, she decided to go to an urgent care center for evaluation. At urgent care, she was diagnosed with urinary tract infection (UTI) and a possible sexually transmitted disease (STD), for which she was given a number of antibiotics, including injection and a prescription for cephalexin.

She states to the doctor that she is still no better despite taking all the prescribed medication from the urgent care clinic. She has ongoing vaginal discomfort, mild discharge, and dysuria, and in the past 2 days she has developed diffuse back pain, a bad headache that is worse on standing or moving. And subjective fevers. She denies of photo-phobia, neck stiffness, nausea, vomiting or other complaints. She says that shed had unprotected sex a few weeks before this all began.


After reviewing her chart, you note that a triage she is afebrile with normal vital signs. However, her temperature was 99.2 °F, which caught your attention. You happened to see her walking into the exam room and noted that she was moving very slowly for a woman her age.

On beside exam she has no photophobia and a supple neck. Her jolt sign is positive. She has mild bilateral CVA tenderness that is worse on the right side. Her abdomen is benign, and her neurological exam is nonfocal.


Urinalysis shows 12 white cell/hpf and no bacteria. Her Complete blood count (CBC) and metabolic panel are both normal

What diagnoses should top your differential?
What additional test should you order?
Where can you get to learn brief tutorial on this?

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