Health Medical Homework Help

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Yerenis Llanes.

Patient Evaluation & Management Plan

A 34-years-old female presents to the clinic with the complaint of sudden and excruciating pain. It is vital to ascertain all the qualifying characteristics as they pertain to the patient’s complaint of pain. As healthcare providers, we can utilize the “OLD CARTS” pneumonic when collecting her HPI. Immediately on hearing the patient’s chief complaint, we can begin to sort out differential diagnosis by asking open ended questions (Dunphy et al., 2019). First, we should inquire about the onset of pain by asking when the problem began, how did it start, and if it has changed over time. Location is clarified by asking the patient where exactly she feels the pain and if the location has changed or radiates. Duration and characteristic are identified by asking if the symptoms are constant, fluctuating, improving or worsening along with qualifiers such as dull, sharp, or electrical. Finally, I would ask about aggravating and alleviating factors that affect her pain, along with any treatments she may have tried. In addition to asking about her pain, understanding the patient’s complaint of nausea is important. I would inquire about the severity and duration, ask of she has vomiting or diarrhea, and obtain a clear understanding as to precipitating factors. Considering her flank pain, I would ask her detailed questions regarding urinary issues, dysuria, or hematuria. One important aspect to consider being a 34-year-old female is to question and confirm whether or not this patient could be pregnant, as this would have implications on the treatment plan.

When it comes to the patient’s physical examination, the first step involves assessing the patient’s vital signs to determine if the flank pain is related to infection, dehydration, or urosepsis. For instance, if the patient has a rapid respiration rate and pulse, is febrile, and shows elevated blood pressure, urosepsis is often suggested. Additionally, an incredibly high temperature reading points toward upper tract infection in the kidney while a low-grade fever is associated with a lower urinary tract infection in the bladder (Brisbane et al., 2016). An examination of the flank area is also crucial for determining mass, asymmetry, and percussion tenderness. To rule out genital, musculoskeletal, and intra-abdominal etiologies, the medical practitioner should order a pregnancy test, examine lower extremities for sensory and motor function, and perform a detailed physical exam.

The first differential diagnosis I would suspect is pyelonephritis. Pyelonephritis is an infection of the kidney that is characterized by infection within the renal pelvis, tubules, or intestinal tissue that may be unilateral or bilaterally (Dunphy et al., 2019). Acute pyelonephritis presents with a classic triad of symptoms which include fever, CVA tenderness, and nausea (with or without vomiting). A second differential diagnoses to consider is nephrolithiasis. Nephrolithiasis is a condition in which stones (renal calculi) originate in the kidney and cause acute episodes of urinary tract obstruction, infection, and severe pain in adults. A third differential would be appendicitis. In the case of appendicitis, patients very often have symptoms of nausea and acute pain in the side that can radiate to the spinal region (Saverio et al., 2020).

At this point, an advanced practice registered nurse should consider the clinical picture and conduct certain tests to determine the etiology of the problem. I would order a urinalysis to check for pyuria, leukocytes, hematuria, proteinuria, alkaline pH, and WBC casts. A urine culture with sensitivity would confirm presence of infection and that we have begun the most effective treatment based on the causative agent. A CBC, CMP, with BUN and creatinine would be standard to assess for infection and kidney function.

Nonpharmacologic management would include the encouragement of increased fluid intake and rest. Initial pharmacological treatment would be a broad-spectrum antibiotic until the culture and sensitivity are available. The patient would also benefit from pain medication, antipyretics, and antispasmodics as needed (Hollier, 2018). I would follow up with her in 48 hours to see if fever, pain, and symptoms are improving or if additional treatment and referral are necessary.

References

Dunphy, L., Winland-Brown, J. E., Brian Oscar Porter, & Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing-An interprofessional approach (5th ed.). F.A. Davis Company.

Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.

Saverio, S., Podda, M., & Catena, F. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15(27).