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Melissa Joiner.
The 34-Year-Old Patient Evaluation & Management Plan
Careful assessment and interview about the onset, intensity, worsening factor, relieving factors about this patient’s complaint of acute right side flank pain will be extremely helpful in appropriate ordering of diagnostic testing, diagnosis, and treatment for this patient. Inquiry regarding the patient’s activity at initial onset of the pain with details about when the pain began, was it immediate intensity or gradual build in intensity. Another question would be to inquire about what if anything made the pain worse for the patient and if there are any relieving factors. Why is the pain decreasing now? Did the patient self-treat with any over the counter or pharmaceutical therapies while at home before presenting to the clinic (Dunphy, 2019).
Considering the patients pain location, cholecystitis should be considered as a differential diagnosis. Inquiry about the patient’s food and drink consumption prior to the onset of her acute pain. Has she had any vomiting associated with the nausea? Has she experienced chilling or hematuria? Does the patient have a surgical history associated with her gastrointestinal system? Another consideration for differential diagnosis would be about the potential for renal calculi. Does the patient have a history of renal calculi or family history would be a pertinent question to present to this patient? The healthcare provider should assess for potential appendicitis during physical assessment for positive or negative Rovsing’s sign (Dunphy, 2019).
Urinalysis with culture and sensitivity to confirm or rule out potential for urinary tract infection. CBC and liver enzymes should also be performed to rule out infection or potential blockage of hepatic biliary system (Delugash & Story, 2020). Consideration of lower back injury or disorder should also be pursued with questions and appropriate testing with Computerized tomography (CT) scan if patient confirms potential with questions during medical history review. A CT scan or ultrasound would also be beneficial in assessment of renal organ to confirm or rule out renal calculi. Considering the patient’s age, an abdominal aneurysm is unlikely but should be considered during medical history interview and physical exam (Rowe, 2021). As well as smoking and alcohol history and or current use. History of hypertension can also be relevant. The management for this patient is to alleviate her pain and nausea with analgesics and antiemetics until diagnosis is confirmed and then medical treatment should be adjusted appropriately to the confirmed diagnosis once obtained (Arcangelo, 2017)
References
Arcangelo, P. V. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach (4th Ed.). Philadelphia: Lippincott Williams & Wilkins American.
Delugash, L., & Story, L. (2020). Applied Pathophysiology for the Advanced Practice Nurse. Burlington, MA: Jones and Bartlett Learning.
Dunphy, M. L.-B. (2019). Primary Care: Art and Science of Advanced Practice. (5th ed.). Philadelphia: F.A. Davis.
Rowe, T. &.-M. (2021, July 19). Diagnosis and Management of Urinary Tract Infection in Older Adults. U.S. National Library of Medicine National Institutes of Medicine : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079031/ (Links to an external site.)
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