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

Download WEEK #7 33- YEAR OLD FEMALE REASON FOR ENCOUNTER: FLANK PAIN COMPLETE CASE STUDY and more Exams Nursing in PDF only on Docsity! 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 33 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: 4/10 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: 23/9/2021 Immunizations: Flu Vaccine: 01/5/2021, COVID-19 Vaccine: 5/6/2020 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: 192/104 98HR 18RR, 98.3T, 99% SPO2 Height: 5’6” Weight: 240 lbs. Body Mass Index: 38.7 Oxygen Saturation: 95 % Pain Scale/Rate: 8/10 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 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.2020.07.046 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