Complaint of a sudden excruciating pain

 

A 34-y.o. female presents with the complaint of a sudden excruciating pain in her back and points to her flank area on the right side. She rates the pain as 10 on a scale of 1 to 10, with 10 being the worst. She also complains of nausea with the pain. She states that she has never had anything like this before, and the pain is subsiding a little now.

What additional questions should you ask the patient and why?
What should be included in the physical examination at this visit?
What are the possible differential diagnoses at this time?
What tests should you order and why?
How should this patient be managed?

 

Sample Solution

Additional Questions

  1. Timing of Pain: When did the pain start? Was it sudden or gradual?
  2. Associated Symptoms: Are there any other symptoms, such as fever, chills, difficulty urinating, or changes in urine color?
  3. Medical History: Any history of kidney stones, urinary tract infections, or abdominal surgeries?
  4. Family History: Any family history of kidney stones or other kidney diseases?
  5. Medications: Are you currently taking any medications, including over-the-counter drugs?
  6. Lifestyle Factors: Any recent changes in diet, exercise, or stress levels?

Physical Examination

  • Vital Signs: Blood pressure, heart rate, respiratory rate, temperature
  • Abdominal Examination: Palpation of the abdomen, focusing on the right flank area. Assess for tenderness, guarding, and rebound tenderness.
  • Back Examination: Palpate the back for tenderness, especially in the costovertebral angle (CVA) tenderness.
  • Genitourinary Examination: If appropriate, a pelvic exam may be necessary to rule out gynecological causes.

Differential Diagnoses

  1. Kidney Stones: A common cause of severe flank pain, often associated with nausea and vomiting.
  2. Pyelonephritis: A kidney infection that can cause severe flank pain, fever, chills, and urinary symptoms.
  3. Renal Colic: Severe pain caused by obstruction of the ureter, often associated with kidney stones.
  4. Pancreatitis: Inflammation of the pancreas, which can cause severe abdominal pain radiating to the back.
  5. Aortic Aneurysm: A life-threatening condition that can cause sudden, severe back pain.

Diagnostic Tests

  1. Urinalysis: To check for blood, infection, or crystals.
  2. Urine Culture: To identify any bacterial infection.
  3. Blood Tests: Complete blood count (CBC), basic metabolic panel (BMP), and renal function tests.
  4. Imaging Studies:
    • Kidney Ultrasound: To visualize kidney size, shape, and any abnormalities.
    • CT Scan of the Abdomen and Pelvis: To identify kidney stones, hydronephrosis, or other abnormalities.

Management

  • Pain Management: Administer pain medication, such as opioids or non-steroidal anti-inflammatory drugs (NSAIDs), as needed.
  • Hydration: Encourage increased fluid intake to help flush out the kidneys.
  • Antibiotics: If a urinary tract infection is suspected, start appropriate antibiotic therapy.
  • Hospitalization: Consider hospitalization for severe pain, dehydration, or other complications.
  • Follow-up: Schedule a follow-up appointment to monitor the patient’s recovery and address any underlying issues.

It’s essential to remember that this is a preliminary assessment based on the limited information provided. A thorough history, physical examination, and diagnostic tests are necessary to make a definitive diagnosis and develop an appropriate treatment plan.

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