A 25-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, which she thought was a yeast infection so she used Monistat. But after 5 days with no improvement, she decided to go to an urgent care center for evaluation. At urgent care, she was diagnosed with a urinary tract infection (UTI) and a possible sexually transmitted disease (STD), for which she was given a number of antibiotics, including an injection and a prescription for cephalexin.

She states 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 photophobia, neck stiffness, nausea, vomiting, or other complaints. She says that she had unprotected sex a few weeks before this all began.


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

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On bedside 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. Her abdomen is benign, and her neurologic exam is nonfocal.


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

What diagnoses should top your differential?

What additional tests should you order?

Where can you get a brief tutorial on this topic?

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