The patient is an African American woman who is 45 years old; she lives in the United States with her husband. As for the most obvious health issues, it is possible to note that the patient is obese and has certain skin problems. The major reason for the patient to seek medical assistance is high body temperature, general weakness, and acute pain in the lumbar region.
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- Chief Complaint (CC): According to the information reported by the patient, she has a few symptoms that have manifested about two days ago. Among the symptoms that she lists, there is the acute pain in the lumbar region, fever heat, and general weakness. Apart from that, the patient claims that she suffers from nausea and pain in the joints.
- History of Present Illness (HPI): As for the history of the present condition, the patient claims that she has never had similar symptoms. The symptoms that she specifies have appeared two days before the assessment, and the patient decided to take pain medication and wait for some time before going to the hospital. More than that, the patient reports that she has chronic ulcerative colitis. Nowadays, she given illness does not have a significant influence on her quality of life, she was provided with a series of treatments about two years ago.
- Last Menstrual Period (LMP): As it is stated by the patient, she has no dysmenorrhea or similar problems, her periods are regular. The last menstruation ended four days before the assessment.
- Allergies: The patient claims that she does not have an intolerance to any medications, including superpotent drugs. As for her food allergies, the patient reports that she has an allergy to tree nuts, green apples. Also, she is allergic to kiwi.
- Past Medical History: The patient was admitted to the hospital two years ago due to her ulcerative colitis, her condition was moderately grave, and the medicinal drugs she was taking included Kaopectate and Remicade (Schiller, 2017). The previous times when the patient was receiving medical help included two cases of severe food intoxication.
- Family History: The father of the patient suffers from hypertension whereas her mother has type II diabetes, both of her parents are obese. The patient’s younger brother and his daughter both have heart problems. The patient has no children.
- Surgery History: The patient had surgery two years ago when she was receiving treatment in the hospital.
- Obstetrical/GYN History: The patient claims that she has never had gynecological diseases except for vaginal yeast. Nevertheless, the patient had two pregnancies at the age of 27 and 33, and she had a misbirth in both cases.
- Social History (alcohol, drug, or tobacco use): The patient has never misused alcohol or drugs, but she has a history of tobacco use. According to her statements, the patient was smoking tobacco regularly for five years (from 1990 to 1995).
- Current medications: Nowadays, the patient still takes certain medications to prevent further spells of ulcerative colitis such as Enteral to treat dysbiosis. Also, she keeps a healthy diet and avoids consuming products that are difficult to be digested.
Review of Systems
- HEENT: The patient reports no eyesight problems, the vision is clear, there are no external problems. No hearing problems are identified, the nose is blocked, the throat is in the normal condition.
- General: There are no significant weight changes; the patient has a general weakness and a fever heat. Certain areas of the skin are covered with rashes (the cheeks and the arms), no itching.
- Cardiovascular system: The patient reports no discomfort in the area or sensations of pain.
- Respiratory system: The patient’s nose is blocked which makes it more difficult for her to breathe, no cough.
- Genitourinary system: The patient reports frequent urination and the absence of menstruation problems, there is erythrocyturia.
- Neurological system: The woman suffers from headaches and nausea.
- Musculoskeletal system: The patient has pain in the joints. There is an acute pain in her lumbar region, which makes it difficult for her to walk.
- Hematological system: No problems except for erythrocyturia are identified.
- Mental health: There are no signs of depression or other diseases.
- Gastrointestinal system: The patient has strong nausea and abdominal pain.
- Vital Signs/ Height/Weight: Pulse rate: 72 RPM, body temperature: 38.9°C. Height: 5.3ft; weight: 176 pounds.
- General Appearance: The patient is obese, and the signs of general weakness are obvious.
- Differential Diagnosis
- Pyelonephritis (Allen, 2016)
- Cystitis (Padilla-Fernandez et al., 2014).
- Urinary stone disease (Chung, 2015).
- Medical Diagnosis
- Pyelonephritis. The given diagnosis seems to be the most appropriate for the case due to the combination of headache, strong low back pain, frequent urination, and hematuria (Roberts, 2015).
Prescriptions with dosage, route, duration, the amount prescribed, and if refills are provided: As is clear from the symptoms reported by the patient, the woman has pyelonephritis, the disease which necessarily involves the use of special medicinal drugs reducing the symptoms. Among the drugs that can be prescribed to the patient considering her present physical condition, there are Amoxicillin (100 mg in the morning and the evening by intravenous administration) which needs to be taken during the next ten days, lisinopril (20 mg daily p.o.) which is to be taken during the next week, and Cyprofloxum, 50 mg two times a week by intravenous administration (Chuhareva, Bontsevich, Shchurovskaya, & Denisova, 2016). The last medicament needs to be taken to prevent further exacerbation of the disease; the patient is supposed to take it during the next three months, gradually decreasing the dosage.
Diagnostic testing needed: Diagnostic testing that needs to be done to retrieve more specific information concerning the prognosis and the course of a disease includes ultrasonography of the kidneys and retrograde pyeloureterography. More than that, the bacterial examination of the urine specimen will be an important measure helping to define the reason for the disease and find out whether there is antibiotic sensitivity.
Problem-oriented education: The patient and her husband must be provided with all the necessary knowledge related to treatment. The latter includes the principles of healthy eating for people with pyelonephritis, the signs of exacerbation, or deterioration of the physical condition.
Interpersonal/Social support/communication: First, the patient needs to be provided with the support of her family members. More than that, to encourage the patient, it can be necessary to provide her with an opportunity to talk to other people with the same diagnosis who are already doing well.
Age-appropriate Health Promotion/Maintenance/Screening Needs: Even though the patient claims to be strictly following the diet due to her gastroenterological problems in the past, it seems that she relaxes the rules or tends to eat in large portions because her weight has not changed since she started keeping a diet. Therefore, the patient needs to have a conversation with a nutritionist who will help her to make changes to her diet so that it would be more effective because her current BMI has a negative influence on her general condition.
Referrals and follow up with rationales: The patient needs to visit a nutritionist to correct her diet and undergo the procedures identified in section 2 to provide healthcare specialists with an opportunity to make changes to the treatment plan where necessary.
Cultural Diversity: Patients belonging to minority rights groups need to be encouraged to seek medical help whenever they need it despite their negative expectations related to the attitude of health professionals.
Patient/Family Education: The patient does not need to take other medications except for the ones identified in section 1 as her previous health issues are not manifested.
The patient is supposed to pay a subsequent visit two weeks after the start of treatment. The results of diagnostic testing will be discussed to define further measures to be taken.
Allen, C. (2016). Education extra: Recurrent urinary tract infections. Australian Pharmacist, 35(2), 36. Web.
Chuhareva, N.A., Bontsevich, R.A., Shchurovskaya, K.V., & Denisova, D.S. (2016). The choice of antimicrobial therapy among physicians in the treatment of gestational pyelonephritis. Research Result: Pharmacology and Clinical Pharmacology, 2(3): 46-50. Web.
Chung, E. (2015). Adult urinary stone disease: A practical approach and management guide. Medicine Today, 16(12): 61-63. Web.
Padilla-Fernandez, B., Bastida-Bermejo, J. M., Virseda-Rodriguez, A. J., Labrador-Gomez, J., Caballero-Barrigon, D., Silva-Abuin, J. M.,… & Lorenzo-Gomez, M. F. (2014). Hemorrhagic cytitis after bone marrow transplantation. Archivos Espanoles de Urologia, 67(2), 167-174. Web.
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Roberts, K. B. (2015). The diagnosis of UTI: Liquid gold and the problem of gold standards. Pediatrics, 135(6), 1126-1127. Web.
Schiller, L. R. (2017). Antidiarrheal drug therapy. Current Gastroenterology Reports, 19(5), 18. Web.