WEEK#vj7vjIvjHUMANvjCASEvjSTUDYvjFORvjAvj33vjYEARSvjOL
DvjFEMALE:vjREASONvjFORvjENCOUNTERvj–
vjFLANKvjPAINvj-
vjNURSvj6512vjADVANCED vjHEALTHvjASSESSMENTvjINCLU
DINGvjSOAPvjNOTE,vjHPI,vjPE,vjDIFFERENTIALvjDIAGNOS
ISvjANDvjMANAGEMENTvjPLAN||vjLOCATION;vjOUTPATI
ENTvjCLINICvjWITHvjX-RAY,vjECG,vjAND
LABORATORYvjCAPABILITIESvjLATESTvjANDvjCOMPLE
TEvjGRADEDvjA+
,2|Page
i- HumanvjCasevjStudyvj–vjWeekvj#7
Course:vjNURSvj6512vj–vjAdvancedvjHealthvjAssessment
Patient:vj33-Year-OldvjFemale
ReasonvjforvjEncounter:vjFlankvjPain
FinalvjDiagnosis:vjAcutevjUncomplicatedvjPyelonephritis
✅vj1.vjPatientvjDemographics
• Age:vj33vjyears
• Sex:vjFemale
• Height:vj5’4”vj(162.5vjcm)
• Weight:vj140vjlbsvj(63.5vjkg)
• BMI:vj24.0vj(Normal)
• Ethnicity:vjHispanic
• Occupation:vjRestaurantvjManager
• MaritalvjStatus:vjMarried
• LivingvjSituation:vjLivesvjwithvjspousevjandvjtwovjchildren
, 3|Page
✅vj2.vjChiefvjComplaintvj(CC)
“I’vevjhadvjthisvjpainvjinvjmyvjrightvjsidevjforvjavjcouplevjofvjdays,vjandvjit’svjgettingvjworse.vjItvj
alsovjburnsvjwhenvjIvjpee.”
Questions
- HowvjcanvjIvjhelpvjyouvjtoday?
- Dovjyouvjhavevjanyvjothervjsymtpomsvjorvjconcernsvjwevjshouldvjdiscuss?
- Whenvjdidvjyourvjflankvjpainvjstart?
- Doesvjanythingvjmakevjyourvjflankvjpainvjbettervjorvjworse?
- Whatvjdoesvjyourvjflankvjpainvjfeelvjlike?
- Howvjsevervj(1-10)vjisvjyourvjflankvjpain
- Arevjyouvjtakingvjanyvjmedicationsvjforvjyourvjsymptoms?
- Wherevjmorevjpreciselyvjisvjyourvjflankvjpain?
- Anyvjchangevjinvjyourvjflankvjpainvjsincevjitvjbeganvj-
vj Hasvjtherevjbeenvjavjchangevjinvjyourvjurinationvjfrequency?
- Doesvjyourvjflankvjpainvjradiatevjsomeplacevjelse?vjWhere?
- Doesvjyourvjflankvjpainvjcomevjandvjgo?
- Arevjyouvjsexuallyvjactive?