Discussion: A 34-Year-Old Patient Evaluation & Management Plan

What additional questions should you ask the patient and why?

The essential questions that I would ask the patient include personal history in relation to the infection. Also, I would ask the patient to state the chief complaint and the history of the present illness. The other question to the patient is when her last menstruation period, any instances of painful urination, and does she experience blood in the urine. Also, I would ask the patient whether the excruciating pain extends to the lower groin and lower abdomen. The other important question to the patient is whether the pain intensity fluctuated and was vomiting. In addition, I would also ask the patient about urinary frequency. In addition, I would ask the patient about any medical and surgical histories. I would also ask the patient about any historical allergies, alcohol, and smoking and illicit drug use. These are important in building the bases for the effective medication of the patient.

What should be included in the physical examination at this visit?

            The patient's physical examination is vital in determining the illness etiology, risk factors, and insights into the infection harmful impacts. The critical physical examination includes assessing the patient blood pressure, heart rate, respiratory rate, weight and temperature. High measures on the above components may indicate a sign of the infection. Therefore during physical examination, vital signs are determined to test any instances of dehydration. The other critical assessment is in the abdomen area; physical examination in the abdomen is essential at assessing pain extent and radiation, and any enlargement of the organ. The other critical examination is the percussion of the flank section that evaluates for instances of tenderness. In such cases, the patients may complain of adverse pain on percussion, which reflects pyelonephritis infection. Other vital tests performed include urinalysis that helps measure PH value, blood in urine, casts and bacteria. Also, a complete blood count is necessary to determine the elevation of white blood cells, which helps indicate the presence of an infection (Asif et al., 2017). Abdominal CT scans and cystoscopy are also crucial in enabling effective diagnosis of the disorder.

What are the possible differential diagnoses at this time?

            The possible differential based on the patient case includes urinary tract tumours, pyelonephritis, traumatic flank pain, musculoskeletal, which causes flank pain and renal artery emboli. The effective diagnosis is the kidney stone, which signs and symptoms include excruciating abdominal pain that extends to the lower hip and abdomen, vomiting, nausea, hematuria and dysuria. The critical medication for the infection consists of hydration therapy and alpha-blockers, essential in minimizing pain.

What tests should you order and why?

            The necessary tests that I would order include lab tests such as urinalysis. The health care will test the urine samples to identify any presence of blood in the urine and any form of mineral that could form kidney stones. The other test is a blood test that involves a blood sample that helps in finding minerals in the blood sample that would contribute to kidney stones. The other tests are imaging tests, including abdominal X-ray that helps locate kidney stones in the urinary tract. The other test is computed tomography scans. CT scans utilize X-ray and computer technologies which helps in observing images of the urinary tract and identify any stones that block the urinary tract, and other factors that may have contributed to the kidney stones (Alelign & Petros, 2018).

How should this patient be managed?

            The effective approach to manage the patient condition includes medical therapy. This includes the use of medication that allow the passage of kidney stones. This treatment consists alpha-blocker that enable relaxation of ureter muscles, thus supporting passage of the kidney stone under less pain (Zisman, 2017). The other infection management approaches are extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy, and ureteroscopy.