A Medical Case Study on Flank Pain and Urinary Tract Infection, Quizzes of Nursing

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i-HUMAN CASE STUDY: C SMITH 33 YEARS OLD

REASON FOR ENCOUNTER FLANK PAIN | REAL

QUESTIONS AND ANSWERS

IHuman C. Smith 33y/o, reason for encounter: flank pain HPI-Christine Smith is a 33 year old female that presents with 2 days of consistentdeep aching flank pain that started out mild as she awakened and was severe by theafternoon. The pain is a 8/10 in the general region of the 12thrib on the right sideposteriorly. Nausea began after breakfast 2 days ago and she has .vomited 3 x’s. Shehas loss of appetite :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...

• (^) The rest of the lung fields are resonant and are not hyper resonant. Chest atraumatic,
• (^) symmetrical; normal AP diameter. Normal respiratory effort and excursion.
• (^) 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