Author: Margaret Giro, DO
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Sally Hinman, MD, PhD

Patient Presentation:
A 20-year-old NCAA Division I golfer had severe abdominal cramping and left lower back pain on a Monday night after dealing with a cold over the weekend. When symptoms persisted, she was instructed to go to student health to be tested for COVID-19, influenza, and mononucleosis; all of these were negative. Due to a concern for kidney stones, she was given ondansetron and emergency room (ER) precautions. As symptoms worsened, the athlete went to a free-standing ER. A computed tomography (CT) scan of the abdomen and pelvis without contrast was performed and did not show kidney stones; she was diagnosed with left moderate hydronephrosis. The ER provider told her that since there was no apparent blockage, she should follow-up outpatient with a urologist for further evaluation. The athlete talked to her trainer and team physician who told her to go to a different ER to be admitted to the hospital for further workup. She denied dysuria, hematuria, change in urinary frequency, fever, and chills, or having similar symptoms in the past. Patient had an episode of emesis that morning.

History:
The patient had no prior medical or surgical history. She had no known allergies to medications, food, or environmental triggers. The patient was a non-smoker and denied alcohol use or illicit substance use. The patient did report a history of constipation. She reported that this had been occurring since she moved to America from her home country and was not a new problem.

Physical Exam:
Initial vital signs: Temperature = 98.6, heart rate = 69, respiratory rate = 18, blood pressure = 145/102, oxygen saturation = 99%.
General appearance: Alert, oriented, resting comfortably, no apparent distress
Eyes: Normal inspection, pupils equal, round, and reactive to light
Head, ears, nose, and throat: Normocephalic
Respiratory: Lungs clear bilaterally, normal breath sounds, no respiratory distress, no accessory muscle use
Cardiovascular: Regular rate, regular rhythm, no murmur
Abdomen: Soft, non-distended, no guarding, pain to palpation in the left lower quadrant
Back: Normal inspection, costovertebral angle tenderness on the left
Neurologic: Alert, oriented to person, oriented to place, oriented to time

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