NURS 680B A 23-year Old Female Complains Of Severe Left Lower Abdominal/Pelvic Pain For 6 Hours
NURS 680B A 23-year Old Female Complains Of Severe Left Lower Abdominal/Pelvic Pain For 6 Hours
A 23-year old female complains of severe left lower abdominal/pelvic pain for 6 hours. States her last menstrual period was “about 3 or 4 weeks ago”. She is sexually active and denies using any contraceptive method.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
A 36-year-old woman presents to the emergency department with left-sided flank pain. The pain is severe, located just below her left ribs, and has been constant for the past 12 hours. It does not radiate or change with position. She also reports a fever to 101°F and general malaise.
What additional questions will further characterize her flank pain and help narrow the differential diagnosis?
What are the common diagnoses associated with flank pain?
Flank pain refers to pain occurring just below the 12th rib, encompassing the costovertebral angle and area lateral to that angle. Patients often describe flank pain as unilateral upper back pain. The initial differential diagnosis depends on the patient’s age, gender, and comorbid illnesses. However, nephrolithiasis, pyelonephritis, and musculoskeletal strain account for most cases.
A careful history often suggests one of these possibilities or raises suspicion for a less common cause. For example, a history of chronic atrial fibrillation increases the likelihood of a renal vascular embolus. Splenic infarct as a cause of left flank pain is unusual but should be considered in patients with suspected endocarditis. If “red flags” arise in the history, life-threatening diagnoses such as rupturing abdominal aortic aneurysm (AAA) or retroperitoneal hemorrhage must also be considered.1
The importance of understanding the reason for presentation cannot be overstated, as the patient’s chief complaint is often critical to determining the final diagnosis. In a young woman with abdominal pain, common maladies must be considered first: cholecystitis, appendicitis, and gynecologic sources—including complications of pregnancy. The young age of the patient effectively excludes diagnoses usually seen in an older population, such as ischemic bowel, diverticulitis, and bowel obstruction.
Expert clinicians start collecting important information as soon as the patient encounter begins. Clinicians compare the data obtained about their patient to their illness scripts for various disorders. Illness scripts are collections of data, such as characteristic symptoms, epidemiologic factors, risk factors, exam findings, or test results that summarize a clinician’s knowledge about a disorder—like a small chapter about a disorder.1Clinicians create a differential diagnosis by including disorders that match the patient presentation and excluding disorders that do not.
While this mental exercise is helpful to exclude some diagnoses, clinicians should keep in mind that patients “don’t always read the textbook” and atypical presentations can be seen. Another possibility is that the clinician’s illness script may be incomplete (for example, due to lack of experience) or may even be inaccurate (for example, caring for unique patient populations). Even though it is highly unlikely that the described patient will have diseases commonly seen in older adults, occasionally younger patients can present with these disorders (i.e. young man with ischemic bowel after using a vasoactive substance such as cocaine). It is helpful to continue to reevaluate the diagnostic possibilities as new information becomes available, and sometimes that includes reconsidering possibilities that we initially thought were highly unlikely.
