NR-511 Wk4 Case Study

NR-511 Wk4 Case Study

NR-511 Wk4 Case Study Part 2

Patient Information

Initial: Patrick

Age: 42

Sex: Male

Race: Caucasian

Subjective:

CC: Nausea, stomach, back pain

HPI:

O: 5 am this morning

L: start out on one side of his back, spreading to his stomach, and shooting down into his groin.

D: 5 am this morning and getting worse.

C: throbbing, shooting, wave like pain to his groin. Cause sweating, nausea and frequency trips to the bathroom.

A: sitting makes it worse, but can’t find any comfortable position

R: nothing helps to relive his pain. Pain is consent.

T: None reported presently

S: Reports pain as 8/10.

Current medication: No daily medication. No herbal medication usage

Allergy: NKDA. Reports hay fever

Immunizations: UTD

PMHx: Describe health as good, Treated for psoriasis last week, but not using presently because symptoms has cleared. No surgeries. Hospitalized at age 8 for broken leg which required traction.

Soc. Hx: Married, has four children. Lives with his immediate family and in-laws. Works full time as a plumber. Work has been so busy no time lately for regular exercise. Smokes a pack of Cigarettes a day. NO ETOH or Illicit drug use. Sleeps 5/6 hours a night

Fam. Hx: Mother (decreased) age 51 from brain tumor, father (decreased) age 53 from leukemia, one (brother) reported to be in good health.

Objective:

Physical Exam:

VS: T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%.

General: Alert, oriented and cooperative

• Head: normocephalic. Hair thick and distribution throughout scalp.
• Eyes: Sclera clear, conjunctiva white
• Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.
• Nose: Nares patent without exudate. Oropharynx moist, no lesions or exudate
• Throat: Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted.
• NECK: supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

Cardio: Heart S1 and S2 noted, no murmurs, noted.

Respiratory:  Lungs clear to auscultation bilaterally. Respiration even and unlabored

• GI: Abdomen appears slightly distended, with decreased bowel sounds noted. Guarding noted on palpation. Positive CVAT on right side. No organomegaly noted.

Diagnoses Test: CBC result are WNL

Urinalysis:  Positive WBCs, Small blood. Trace protein, pH 7.0 Sp Gr 1.030, neg ketones, neg glucose

Ultrasonographer: report show a smooth round calculus is noted at the junction of the ureter and the bladder.

NR-511 Wk4 Case Study

Assessment:

Dx: Nephrolithiasis- (ICD9-592.9)

1. …

2. Urinary Tract Infection: (ICD9-599.0) – …

Plan

…

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References:

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis.

Wolf, Stuart J. (2014). Nephrolithiasis clinical presentation. Retrieved from   http://emedicine.medscape.com/article/437096-clinical