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A case study of flank pain, focusing on the diagnostic and management process. It includes discussion questions that explore missed questions during history collection, errors in physical exam performance, key findings and further evaluation, missed assessment categories, and incorrect differential diagnoses. Insights into the importance of thorough history taking, accurate physical examination, and appropriate diagnostic testing in managing flank pain.
Typology: Exams
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1. Patient Information Name : i-Human Case Week # Age : 33 years Height : 5’6” (168 cm)
Weight : 130.0 lbs (59.1 kg) Reason for Encounter : Flank pain
Location : Outpatient clinic with x-ray, ECG, and laboratory capabilities
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain. Discussion Question One Obtaining the history of a particular patient is an important aspect when undertaking patient diagnosis. The main rationale of evaluating the history of the patient is to ascertain the previous health conditions of the individual(Hamasuna et al,2015).A close evaluation of the case under study reveals that I missed some important questions that could have helped me to arrive at the correct diagnosis. One of the vital questions that I missed pertaining to the case under evaluation is; When did the pain in your Flanks start? This question is important regarding the case under evaluation. For Mrs. Smith, asking of such question would have helped in ascertaining the severity of the pain. Additionally, asking the question would help in determining the duration that the individual has been experiencing the pain. Another important question that I missed during the evaluation of the history of the patient is; Does anything make the pain in your frank better or worse? The asking of the aforementioned question would have helped in determining the factors that trigger pain. Furthermore, the question could have aided in ascertaining the risk factors that accelerate the pain. Determining the risk factors that contribute to the pain could have helped in the correct diagnosis and identifying of the effective therapies and interventions for Mrs. Smith (Hamasuna et al,2015).
Moreover, the determination of the risk factors could have helped in identifying the factors that Mrs. Smith should not be exposed to. Another important question that I missed during the evaluation of the history of the patient is; Where more precisely is your flank pain? The main rationale as to why this question should be included is that it could have aided in determining the particular area of pain hence leading to a correct diagnosis. Ideally, I missed asking Mrs. Smith how the pain in her flanks feel like. This question could have aided in arriving at the correct diagnosis. DISCUSSION QUESTION 2 Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client. Discussion Question Two From the case under evaluation, it is imperative to denote that I performed some errors during the physical evaluation of Mrs. Smith. One of the errors that I performed during the physical assessment of Mrs. Smith is that I bumped the blood pressure cuff too high when I was measuring the blood pressure of Mrs. Smith. When the blood pressure of an individual is being evaluated, it is vital to make use of the appropriate blood pressure cuff in order to attain the correct measurement of the blood pressure (Hamasuna et al,2015). Given the fact that I pumped the blood pressure too high, there is a likelihood that I obtained false high readings. Another error I performed during the physical evaluation of Mrs. Smith is that I did not determine the radial pulse of Mrs. Smith when she was in the conscious state. Determination of the radial pulse of the individual in her conscious state would have helped in arriving at the right depiction
(Hamasuna et al,2015). Through that evaluation, I could have ascertained the variation of the radial pulse of the patient both in her conscious and unconscious state. A close evaluation of the physical assessment that I carried out on the patient depicts that I failed to count two beats in the needed location. This postulation gives an implication that the patient might have altered the speed of breathing resulting in wrong readings. Additionally, I failed to carry out auscultations in all the required respiratory locations. This physical assessment could have helped in determining the other signs and symptoms which were not obtained through the physical evaluation that was undertaken. DISCUSSION QUESTION 3 Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text. Discussion Question Three One of the key findings that I included in my list is Pyelonephritis. It is used to refer to the malfunction that results in the swelling and damaging of the kidneys. The condition occurs when the renal parenchyma is invaded by the bacteria (Chivima, 2014). The bacteria can pass through the bloodstream or the lower urinary tract and reach the kidney. To further diagnose the disorder identified in the case of Mrs. Smith, I would carry out various diagnostic tests. One of the diagnostic tests that I would carry out is the use of microscopic urinalysis. The main rationale for administering this test is that it would aid in ascertaining the presence or absence of the white blood cell casts. The presence of the white blood cells cast would depict that the
individual has the condition of renal origin pyuria which supports the diagnosis of acute pyelonephritis (Johnson and Russo, 2018). I would also carry out an antimicrobial susceptibility testing and urine culture testing. The main rationale for advocating for the aforementioned diagnostic test is that it could help in guiding the adjustment of the previous antimicrobial regimen. (Chivima, 2014). If the symptoms would not improve after carrying out of the stated tests, then I would carry out imaging. Imaging is mainly carried out to ascertain the structural abnormality (Johnson and Russo, 2018). In this case, I will embrace the use of magnetic resonance imaging in ascertaining further obstruction. I will also embrace the use of blood culture. Blood culture would be used in ascertaining the causing organism of acute pyelonephritis in the case of Mrs. Smith. DISCUSSION QUESTION 4 Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client. Discussion Question Four Based on my evaluation of the identification of the problem categories, it is vital to denote that I missed some important categories and examination that would have aided me to arrive at the correct diagnosis. One of the evaluations that I missed is that I failed to palpitate all the lymph nodes. Ideally, palpitation of the lymph nodes would have aided in the evaluation of lymphadenopathy with fever. Additionally, I missed percussing the spine and the back. Typically, percussing of the pain and the back is recommended for individuals who present with flank pain (Hamasuna et al,2015). However,
before percussing, it is important to palpitate and inspect. Ideally, this is because a patient with tenderness on palpation may experience intense pain during percussion (Hamasuna et al,2015). Furthermore, I failed to carry out a gynecological examination such as a rectal examination, bimanual examination, specimen evaluation, speculum examination and external visualization. A close evaluation of the physical assessment that I carried out on Mrs. Smith also depicts that I had some incorrect categories. For instance, I performed some of the tests that were not required. For instance, I inspected the eyes and palpitated the neck. Moreover, I auscultated the carotid and femoral arteries. Important to ascertain is that auscultation of the carotid and femoral arteries is not required for the patients who present with flank pain (Hamasuna et al,2015). Other incorrect categories include; the inspection of the chest and lungs, evaluation of the skin color, distribution and thickness. DISCUSSION QUESTION 5 Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client Discussion Question Five One of the differential diagnosis that I missed during the diagnosis is an ectopic pregnancy. Ectopic pregnancy is known to occur when the fertilized egg attaches itself outside the primary cavity of the uterus (Jiang et al,2014). The main rationale as to why ectopic pregnancy would have been included as a differential diagnosis is that pelvic pain is among the signs and symptoms associated with ectopic pregnancy. Fainting, abdominal vaginal
bleeding, breast tenderness, missed periods, dizziness, and nausea are other symptoms that are associated with ectopic pregnancy. Another differential diagnosis that I should have included in the evaluation of the condition of Mrs. Smith is appendicitis. Appendicitis is used to denote the condition whereby the appendix becomes inflamed (Rauf, Ahmad and Husaain, 2018). The main reason as to why Appendicitis should have been included as a differential diagnosis in the case under evaluation is that it manifests periumbilical pain during the earlier stages. This pain usually moves to the right lower quadrant. Another symptom associated with periumbilical pain is nausea. Individuals with such conditions experience dizziness and vomiting. According to Mrs. Smith, she experienced pain in the right flank. However, she may have developed periumbilical pain which she was not aware. Important to depict is that I also missed acute pancreatitis as one of the differential diagnosis in the case under evaluation. Pancreatitis is used to denote the condition whereby the kidney of an individual becomes inflamed (Garg and Rustagi, 2018). The condition occurs when activation of the digestive enzymes takes place before the enzymes are released to the small intestines. Acute pancreatitis can damage the tissues, result in the formation of a cyst and even gland bleeding (Garg and Rustagi, 2018). It can also result in the damage of the kidney, the heart, and the lungs. The main rationale as to why acute pancreatitis should have been included as a differential diagnosis is that it manifests the symptom of abdominal pain, nausea, and vomiting. Additionally, patients with the condition of acute pancreatitis present with the symptoms of anorexia, hypertension, and fever (Garg and Rustagi, 2018). Such individuals also present with symptoms such as; swelling of the abdomen and increase of the heartbeat. Kidney calculi is another vital differential diagnosis that missed in the category. Kidney calculi are used to refer to the condition in which the solid
masses are formed in the kidney (Shadman and Bastani, 2017). The primary reason as to why the kidney calculi malfunction should be included in the differential diagnosis is that it includes symptoms such as; back pain, nausea and vomiting, and radiating pain to the groin and the lower abdomen. Since Mrs. Smith presented with such conditions, therefore, it is imperative to include kidney calculi in the list of differential diagnosis.
2. HPI (History of Present Illness) Statement Summarize the patient’s primary complaint (flank pain) in detail: o Onset (When did the pain start?) o Location (Exact site of pain—unilateral or bilateral flank?) o Quality (Dull, sharp, throbbing, or other descriptors?) o Severity (On a scale of 1 – 10, how bad is the pain?) o Timing (Constant, intermittent, or related to any activity?) o Associated symptoms (Fever, chills, urinary symptoms like dysuria, hematuria, etc.?) o Modifying factors (Anything that worsens or alleviates the pain?)
3. History (Interview Questions) Focus on key areas to uncover potential underlying causes: o Medical History : History of kidney stones, UTIs, or other genitourinary conditions? o Surgical History : Any past surgeries involving the urinary tract or abdomen? o Family History : Family history of kidney disease, stones, or other hereditary conditions? o Social History : Diet (High salt or oxalate intake?) Hydration habits (Daily water intake?) Smoking, alcohol, or drug use (Substances that may affect renal function)? o Medications : Use of diuretics, NSAIDs, or supplements (e.g., vitamin C)? o Review of Systems (ROS) : General: Fever, fatigue, weight loss? Genitourinary: Dysuria, frequency, urgency, hematuria? GI: Nausea, vomiting, constipation, or diarrhea? 4. Physical Exam Findings General appearance: Alert or in acute distress? Vitals : o Blood pressure
o Heart rate o Respiratory rate o Temperature Focused Exam : o Abdominal: Tenderness in the flank region? Palpable masses? Signs of peritoneal irritation? o Genitourinary: Costovertebral angle (CVA) tenderness? o Cardiovascular: Normal or abnormalities?
5. Diagnostic Testing Initial Tests to Consider : o Urinalysis (UA): Look for blood, protein, or signs of infection. o Complete blood count (CBC): Assess for infection or anemia. o Basic metabolic panel (BMP): Evaluate kidney function (creatinine, BUN). o Imaging: X-ray: Assess for kidney stones. Ultrasound: Evaluate for hydronephrosis or masses. CT Scan (non-contrast): Gold standard for diagnosing renal stones.
6. Differential Diagnosis (Ranked and Justified) 1. Nephrolithiasis (Kidney Stones) o Supporting signs: Flank pain, hematuria, history of stones, or imaging findings. 2. Pyelonephritis o Supporting signs: Fever, chills, CVA tenderness, leukocytosis, or positive urine culture. 3. Musculoskeletal Strain o Supporting signs: History of trauma or activity, localized tenderness, absence of systemic symptoms. 4. Hydronephrosis (Secondary to Obstruction) o Supporting signs: Imaging findings, pain with progression over time. 5. Other Possibilities : GI causes (appendicitis, diverticulitis) or gynecological issues (e.g., ovarian torsion). 7. Plan (Critical Components) Treatment/Management Plan : 1. Acute Pain Management : Analgesics (e.g., NSAIDs, acetaminophen). 2. Hydration : Increase oral or IV fluids to assist stone passage. 3. Specific Interventions (Based on Diagnosis): Nephrolithiasis:
Alpha-blockers (e.g., tamsulosin) to aid stone expulsion. Urology referral if stone >10 mm or obstructive. Pyelonephritis: Antibiotics (e.g., ciprofloxacin or ceftriaxone). Hydronephrosis: Address underlying cause (e.g., obstruction, mass).