WEEK #7 33- YEAR OLD FEMALE REASON FOR ENCOUNTER: FLANK PAIN COMPLETE CASE STUDY, Exams of Nursing

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COMPREHENSIVE I HUMAN CASE WEEK # 7 33 -

YEAR OLD FEMALE REASON FOR ENCOUNTER:

FLANK PAIN COMPLETE CASE STUDY NEWLY

RATED – WALDEN UNIVERSITY

Chief Complaint flank pain

History Of Present Illness

Patient is a 3 3 yrs old female with past medical history of Type 2 Diabetes Mellitus who presents with flank pain and pelvic pain 4/10 in severity, constant, radiating to the left abdomen and suprapubic region x 3 days. Noted concomitant dysuria but no hematuria. No fever or chills. No nausea or vomiting. Last BM was yesterday. Patient noted that she had similar flank pain in the last 6 months during which she was found to have pyelonephritis and prescribed antibiotics with resolution. Stated that her flank pain feels similar to the previous episode. Patient history notable for cholecystectomy done 2 yrs ago. Lives at home with husband and 2 kids. Sexually active with one male partner. Feels safe at home. Drink 2 - 3 beers once per month. No tobacco or recreational drugs. Allergies No Known Allergy Code Status Full Code

Past Medical History

Diabetes Mellitus Type 2 Pyelonephritis Fatty Liver

Past Surgical History

Laparoscopic Cholecystectomy (2022) Cesarean Section

Vital Signs

Temp: 37.1 Heart Rate: 82/min Respiratory Rate: 18/min BP: 118/74 O2 Sat: 98% Pain: 4/

Physical Exam

Ears/Nose/Mouth/Throat: head normocephalic, oropharynx clear, no erythema or exudate. No lymphadenopathy. Eyes: extraocular movements intact, PERRLA Cardiovascular: no chest pain, no palpitations, no syncope Respiratory: lungs clear to auscultation bilaterally Gastrointestinal: positive suprapubic pain, regular bowel sounds, abdomen soft and non-tender Musculoskeletal: left flank pain, no bilateral extremity edema Skin: warm, dry and intact

Laboratory Report Complete

Blood Count (CBC)

WBC - 11.6 K/cumm RBC - 4.65 M/cumm Hgb - 14 g/gL Hct - 41.6% Platelet - 276 K/cumm

Basic Metabolic Panel (BMP)

Sodium - 133 mmol/L Potassium - 3.8 mmol/L Chloride - 100 mmol/L CO2 - 19 mmol/L Blood Urea Nitrogen (BUN) - 10 mg/dL Creatinine - 0.72 mg/dL Glucose - 329 mg/dL Calcium - 8. mg/dL

Liver Function Test (LFT)

Albumin - 3.3 g/dL Alkaline Phosphatase - 118 U/L Alanine Transaminase (ALT) - 20 U/L Aspartate Aminotransferase (AST) - 17 U/L

Bilirubin Direct - 0.3 mg/dL Bilirubin Total - 1.3 mg/dL

Urinalysis

WBC - 50+ HPF

Ketones - 150 Bacteria - Few Nitrite - Negative Leukocytes - trace Glucose - 1000+ Urine Culture (pending result)

Medications

Toradol 60 mg IM once for pain Ertapenem Sodium (Invanz) 1 Gm IVPB to infuse 60 mins x 1 dose Piperacillin/Tazobactam (Zosyn) 3.375 Gm IVPB to infuse 30 mins x 1 dose Doxycycline 100 mg PO 1 capsule Q 12 hours Metformin 500 mg PO BID Glipizide 10 mg PO BID daily with meals Atorvastatin 40 mg 1 tablet daily

Medical Decision Making

Will admit patient for antibiotics and blood sugar control 1 Liter Normal Saline CBC daily Pain control PRN with Tylenol, Oxycodone If no improvement of clinical status, consider CT abdomen and pelvis

Past Medical History Chronic Condition: Kidney stones, HTN, and seizures Current Medication: Lisinopril, Lamictal, and insulin Hospitalization: Once in the past month. History of mental illness: None Physical trauma or falls None. Surgeries: Unremarkable. Exposure: None Environmental exposure: None Exercise: The patient does not exercise Diet: The patient notes that she does not pay attention to dietary practices Social History: Married with two children. Toxics Habits: Current heavy smoker (2 packs of cigarettes daily). Pt denies using drugs or alcohol. Educational level: High school. Sexual Behavior: The patient is heterosexual and the husband always uses a condom. No risk behaviour for STDs. Allergies: NSAIDS, Toradol, Keppra, and Phenergan Family Medical History: Mother and father are alive and both have suffered from IDDM and HTN. Pt also notes that the family has a history of kidney stones and seizures. Preventive service: Last annual physical exam: 23/9/ Immunizations: Flu Vaccine: 01/5/2021, COVID-19 Vaccine: 5/6/ Review of systems (ROS) Systemic: Pt denies weight loss, fever or chills Head: Normocephalic Neck: No pain or discomfort.

Eyes: Denies blurred vision. Eye pain absent. Oto-laryngeal: Proper dentition, no hearing loss. Breasts: Pain, fullness, and discomfort absent. Appropriate for females. Cardiovascular: Negative for chest pain, palpitations, irregular rhythm and edema. Pulmonary: SOB absent. Cough and pleuritic pain absent. No chest pain. Gastrointestinal: No dysphagia or heartburn. No diarrhea or constipation. Bloating absent. Nausea present. Right flank pain. Mid and lower back pain. Genitourinary: Positive for dysuria and haematuria. Bloody urine. No vaginal discharge. Endocrine: No symptoms. No polyuria, no polyphagia. Polydipsia absent. Hematologic: No abnormal bruising. Normal distribution of hair based on gender. loss of hair, Tolerance to heat/cold intolerance No changes in nails Musculoskeletal: Denies muscle pain. Confirms full mobility. Positive for lower back and right flank pain. Normal ROM. Neurological: Alert. Denies migraine. LOC absent. No dizziness, fatigue or Denies migraine, balance problems, seizures or fainting lightheadedness, tremors or balance problems. Denies muscle weakness, numbness or tingling. Psychological: Demonstrates effective judgment and does not display suicidal ideation. No sleep disturbances. Depression and anhedonia absent. Skin: White or brown spots absent, ulcer, ecchymosis, or new nevus. No bruises. Negative for heat and cold intolerance. Nor abnormal bruising and bleeding.

OBJECTIVE

Physical Exam Vitals Sign: 192/ 98HR 18RR, 98.3T,

99% SPO

Height: 5’6” Weight: 240 lbs. Body Mass Index: 38. Oxygen Saturation: 95 % Pain Scale/Rate: 8/ General appearance: The patient is a well developed, well-nourished and well-groomed obese female who is crying and visibly restless. Head: The skull is Normocephalic and atraumatic. No masses present. The normal strength of muscle contraction is shown in palpation of the temporal and masseter muscles. Naso-labial folds are symmetrical. Neck: Normal colouration. No visible masses. Palpable masses absent. Skin non-tender. Normal lymph nodes. Nodules are absent in the thyroid. Eyes: Symmetric extraocular movements in both eyes. PERRLA, the sclera is white, conjunctiva pink, no noted discharge. Visual acuity is absent. Ears: Normal external auditory canal and meatus. Pink TMs are non-bulging. EAMs negative for debris. No erythematous, scarred or hemorrhage Nose: No nose deformities. The nasal mucosa is moist and pink with clear drainage. Oral Cavity: Healthy gums. Pink and moist oral mucosa Pharynx: No petechial, Tongue: moist. Lymph Nodes: No adenomegaly. Respiratory: Lungs clear of auscultation and percussion. JVD absent. Negative for wheezing, coughing, and rhonchi. Cardiovascular: Regular rate and rhythm, heart sounds of S1 and S2, no extra heart sounds, murmurs or bruits noted. Pulses +2 x bilateral UE and LE. Skin appropriate for ethnicity. Capillary refill less than 2 seconds all extremities

Gastrointestinal: No palpable masses. Hepatosplenomegaly absent. There is no Costovertebral angle (CVA) tenderness absent. Genitourinary: Deferred Musculoskeletal: Upon inspection, full, normal ROM at all extremities. Normal gait and posture. No pain or tenderness was noted. Muscle strength testing is 5/5. Neurological: Intact cranial nerves. 5/5 motor strength in all extremities. Intact sensory. Psychiatric: Pt is aware of time, place, and situation. Fluent speech. No suicide ideation. Mild anxiety is present due to the pain. No memory relapse. GCS 15. No hallucination or illusions. Higher cognitive functions are intact. Upon assessment, the patient can conduct simple calculations. Skin: No signs of infections. Nevi absent. No abnormal bruising. Clean, warm, and dry skin. Hair: Normal hair distribution based on gender. Nails: Pink with normal appearance.

ASSESSMENT

Primary Diagnosis:

1. Hematuria

The patient presents with hematuria given that there is no scan done to determine the presence of the kidney stone she reports having been diagnosed with 23 days prior. In essence, hematuria is the primary diagnosis because of the signs and symptoms the patient presents with. Indeed, testing for the condition is likely to confirm the diagnosis – microscopic urinalysis should be used alongside simple urinalysis to ascertain the presence of actual blood in urine thereby offering essential insight for further diagnosis (Orlandi et al., 2018). One of the rationales for hematuria s that the condition may be caused by renal or bladder calculi which was confirmed by the patients' medical history and diagnosis. Moreover, the flank pain and renal colic are additional evidence to determine that hematuria is the cause of pain and discomfort given that renal calculi pass through the urinary tract from the kidney.

2. Urinary calculi

This diagnosis is based solely on the patient's medical history and a visit to the ED. The pain and discomfort is likely a consequence of passing the kidney stone which was diagnosed in previous hospital visits. Hematuria, renal colic, and flank pain are hallmarks signs and symptoms of passing a kidney stone. According to Feit et al. (2021) radiating pain from the flank and back coupled with blood in the urine are the most reported signs and symptoms of nephrolithiasis. Therefore, the current diagnosis fits the clinical manifestation of urinary calculi based on the patient's complaints and medical history. Differential Diagnosis:

1. Gastroenteritis. A differential diagnosis that may suffice in this case is gastroenteritis evidenced by the presence of nausea and flank pain. However, given that the paint does not report diarrhea or changes in stool, the symptoms do not support the diagnosis of gastroenteritis.
2. Abdominal Aortic Aneurysm Given that the patient presents with urinary retention and renal colic, a differential diagnosis may be AAA. Nonetheless, testing should be conducted in the earliest time possible because AAA is linked with mortality due to the impact of ruptured blood vessels on the body. Still, the patient may not be suffering from AAA because of no hypertension or hypotension upon reporting to the hospital. Based on the CT scan conducted 15 days ago when identifying the kidney stone, it is likely that AAA is not present because it would have been noted in the respective CT images.

PLAN

The main plan for this patient was to reduce the pain and control the associative symptoms that would present with passing the kidney stone. While in the hospital, the patient was given Percocet 5/325mg and Zofran 4mg PO for pain and nausea. Nonetheless, the patient was not able to pass the stone and there was a need to discharge her with the necessary medication. Moreover, part of the treatment plan was to see a nephrologist who would provide her with the essential knowledge and care during the process.

Labs/diagnostic Test:

• CBC with differential.
• BMP
• CT scan Pharmacologic Treatment: The patient was prescribed for the following:
  • Flomax 0.4mg PO once a day,
  • Percocet 5/325mg 1-2 tabs PO q4-6 hours PRN,
  • Zofran 4mg 1 tab BID PRN. Non-Pharmacologic Treatment: The patient was instructed regarding general measures:

1. Limit animal protein consumption

2. Reduce sodium intake

3. Eat calcium-rich foods

4. Avoid foods with high amounts of oxalate phosphate

5. Smoking cessation.

Education: The main insight the patient was given was on the essence of having the necessary medication and following up on the prescription. Smoking cessation and avoiding alcoholic drinks were also advised at this moment. Follow-ups/Referrals: The patient notified the physician that she was already seeing a nephrologist but she was advised to communicate with the professional immediately after discharge given the criticality of her condition. Moreover, the patient was educated on the essence of following up on her medication before they are close to getting finished to avoid onset and recurrence of severe symptoms in case the stone does not

pass within the defined timeframe. Overall, she was advised to communicate with the PCP who would conduct health promotion and maintenance of any underlying conditions. References

References Feit, L., John, D., Delgado Torres, N., & Sinert, R. (2021). Flank pain and hematuria is not always a kidney stone. The American Journal of Emergency Medicine, 40. https:/doi.org/10.1016/j.ajem.2020.07. Orlandi, P. F., Fujii, N., Roy, J., Chen, H., Lee Hamm, L., Sondheimer, J. H.,... Feldman, H. I. (2018). Hematuria as a risk factor for progression of chronic kidney disease and death: Findings from the Chronic Renal Insufficiency Cohort (CRIC) study. BMC Nephrology, 19 (1). https:/doi.org/10.1186/s12882- 018 - 0951 - 0