Walden University - NURS 6550N Week 9 IHuman Interview Questions (Solution) UPDATEDMr. Jason Towns is a 32 y.o male with PMH HTN and back pain related to
... [Show More] occupation, presents with acute
onset of left flank pain radiating to left groin starting about 2 hours ago. The pain is described as a sharp,
shooting, stabbing pain rating it a 7/10. He states he has never had pain like this before. Initially related it
a pulled muscle when he first felt it the night before until about 2 hours ago. The pain is intermittent and
comes in cycles causing pain to be bearable to unbearable, and then it goes away. When pain intensifies, he
is unable to take a deep breath due to pain, stating he is only able to take shallow breaths. Endorses
nausea and vomiting, especially with the unbearable episodes of pain. The patient describes the vomitus
as undigested food. Mr. Towns endorses taking Tylenol for pain, as well as using ice and heat to the area
without relief of symptoms. Denies chest pain, SOB, fevers, chills, diarrhea. Urinary symptoms include the
inability to initiate urine stream, and urine is darker in color than normal per patient. No dysuria,
hematuria, pyuria, urgency, or frequency. The patient is noted to be mildly diaphoretic, appears restless
and unable to sit still. Denies tobacco or illicit drug use. He does drink 1-2 drinks on the weekend. He
works in construction but denies any known injury. He takes HCTZ for blood pressure which is controlled.
FMH positive for cardiovascular disease, HTN, DM, and arthritis. Mr. Towns is afebrile, tachycardiac, and
hypertensive at time of assessment.
Primary Diagnosis: Nephrolithiasis/kidney calculi
Status/Condition: Stable
Code Status: Full
Allergies: NKA
Admit to Unit: Medical
Activity Level: as tolerated
Diet: NPO
IVF: 18g IVL x 2 1L bolus then NS at 125 ml/hr.
Critical Drips: N/a
Respiratory: N/A
Medications:
Hold HCTZ (can cause hyperuricemia)
Amlodipine 5 mg PO now and then QD
Tamsulosin 0.4 mg PO now and then QD
Metoclopramide 10 mg IV q6h PRN for N/V
Toradol 30 mg IV now and then 15 mg IV Q6H pain
Acetaminophen 1000 mg IV Q6H PRN fever greater than 101.5, pain less than 5.
maximum 4000 mg/day
and CMP daily.
2 | P a g eConsults: Current diagnosis & treatment: Surgery (14 (58 Pocket Medicine. The Massachusetts General Hospital Handbook of Internal Medicine (6 Pathophysiology of nephrolithiasis Call your healthcare provider right away if you have any of the following: [Show Less]