I HUMAN CASE WEEK #7 COMPREHENSIVE 33- YEAR OLD FEMALE REASON FOR ENCOUNTER: FLANK PAIN C, Exams of Nursing

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I HUMAN CASE WEEK #7 COMPREHENSIVE 33 - YEAR OLD

FEMALE REASON FOR ENCOUNTER:

FLANK PAIN COMPLETE CASE STUDY DECEMBER

VERSION

WALDEN UNIVERSITY

:Questions

• How can I help you today
• Do you have any other symtpoms or concerns we should discuss
• When did your flank pain start
• Does anything make your flank pain better or worse
• What does your flank pain feel like
• How sever (1-10) is your flank pain
• Are you taking any medications for your symtpoms
• Where more precisely is your flank pain
• Any change in your flank pain since it began - Has there been a change in your urination frequency
• Does your flank pain radiate somepalace else? Where?
• Does your flank pain come and go
• Are you sexually active
• Is your urine pink or red in color
• Tell me about the health of your grandparents, parents …
• Do you havve any allergies
• Are your immunizations up to date
• Are you taking any prescription medications
• Are you taking any over-the-counter or herbal medications
• Is your period late
• When did your last period begin

• When did your fever start
• How high is your fever
• Do you have pain/ discomfort when you urinate
• Are you having any problems with your periods
• Can you tell me about any current or past medical problems...
• Any previous medical, surgical....
• Have you ever had abdominal surgyer
• When you urinate, have you noticed any pain, burning...
• Do you have any problems with gatigue, difficulty sleeping....
• Do you have any problems with an itchy scalp, skin changes...
• Do you have any problems with headaches that don’t go away with aspirin...
• Have you noticed any breast discharge, lumps....
• Do you experience chest pain discomfort or pressure...
• Do you experience shortness of breath, wheezing, difficulty catching your breath....
• Do you have problems with nausea, vomiting, constipation...
• Do you have problems with muscle or join pain, redness...
• Have you noticed any bruising, bleeding gums...
• Do you have problems with heat or cold intolerance, increased thirst... - Do you have problems with dizziness, fainting, spinning room... Key findings

1. Recurrent bladder infections
2. Flank pain
3. Nausea/ vomiting
4. Fever

:Physical Exam

• Fever, tachycardia, right CVA tenderness to percussion o Temp 101F o HR 114 o BP: supine 120/60 o RR: 14 o Cognitive : A and OX 4
• HEENT Neck: EOMI, normal visual fields, normal sclerae, Normal dentition, Pupils - equally round and reactive to light with accommodation, Atraumatic.
• Eyelids: no ptosis erythema or swelling. Conjunctivae: pink, no discharge.
• Sclera: anicteric. Orbital area: no edema, redness, tenderness, or lesions noted. - Neck: No visible scars, deformities, or other lesions. Trachea is midline and freely - mobile. No asymmetry or accessory respiratory muscle use with quiet breathing.
• Respiratory: The anterior chest on the left and right lower chest are dull to percussion. - The rest of the lung fields are resonant and are not hyper resonant. Chest atraumatic, - symmetrical; normal AP diameter. Normal respiratory effort and excursion. Tachycardia

• Cardiovascular: +tachycardia. Regular rate and rhythm; no murmurs, rubs, gallops, No - edema or cyanosis, 2+ pulses bilaterally (radial; PT), No peripheral edema.
• Abdomen/Gastrointestinal: Not tender to RUQ Palpation; voluntary guarding present, no - rebound. No Murphy's sign. Reported discomfort with right flank percussion.
• Genitourinary: + right CVA tenderness to percussion.
• Neurological: Negative
• Skin/Breast: Warm, dry
• Allergic/Immunologic: None/Normal
• Lymphatic/Endocrine: No adenopathy, No regional lymphadenopathy, No localized - edema
• Hematologic: No bruises or signs of abnormal bleeding, or petechiae - MSK: Negative