On further questioning Patrick has no report of further headaches, no fever, or vision changes. No report of nasal congestion, or discharge. No report of wheezing or shortness of breath with rest, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Position changes and Tums did not relieve the pain, he did not try to take any other medication, he did not think he could keep it down if he tried because he is so nauseous.
Physical exam:
VS Height: 5 feet 9 inches weight: 198 pounds
T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%.
Reports current pain as 8/10. Describes back and stomach pain as throbbing. The pain seems come in waves and at time shoots down into his groin.
General
Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear, conjunctiva white.
Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored.
Abdomen appears slightly distended, symmetric with no visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or tenderness. Positive CVAT on right side.
Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative nitrites, negative ketones, negative glucose
CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL
You send Patrick to the in-house ultrasonographer. The report states “a 5mm smooth round calculus is noted at the junction of the ureter and the bladder:
Discussion Part Two:
Summarize the history and results of Patrick’s physical exam and then answer the additional case study questions below.
List the primary diagnosis with ICD10 code. Include your evidence-based rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document.
Answer these additional questions in this post regarding this case:
What should the NP do if Patrick continues to come back for pain medication?
What are possible warning signs of prescription drug abuse?
List three of the twelve 2016 CDC recommendations that would help the provider in handling this case.
