A 34-y.o. female presents with the complaint of a sudden excruciating pain in her back and points to her flank area on the right side. She rates the pain as 10 on a scale of 1 to 10 with 10 being the worst. She also complains of nausea with the pain She states that she has never had anything like this before, and the pain is subsiding a little now.
1. What additional questions should you ask the patient and why?
2. What should be including in the physical examination at the visit?
3. What are the possible differential diagnoses at this time?
4. What tests should you order and why?
5. How should this patient be managed?
Sample Solution
Patient Presentation: 34-year-old Female with Acute Flank Pain
1. What additional questions should you ask the patient and why?
Given the sudden onset, excruciating nature, and location of the pain, the primary concern is renal colic, but other serious conditions must be ruled out. Here are additional questions and their rationale:
Character of the Pain:
- "Can you describe the pain more specifically? Is it dull, sharp, stabbing, burning, colicky (comes and goes in waves)?"
- Why: Colicky pain, especially radiating, is classic for renal colic. Sharp, stabbing pain could suggest other issues, while dull pain might point to infection or musculoskeletal.
- "Does the pain radiate anywhere else (e.g., groin, lower abdomen, thigh, back to the shoulder)?"
- Why: Radiation patterns are crucial. Pain radiating to the groin or genitals is highly indicative of ureteral colic. Radiation to the shoulder could suggest diaphragmatic irritation (e.g., splenic rupture, pneumonia).
Associated Symptoms:
- "Have you had any fever or chills?"
- Why: Fever and chills with flank pain strongly suggest pyelonephritis (kidney infection), which is a urological emergency.
- "Have you noticed any blood in your urine (hematuria)? Even a pinkish tint?"
- Why: Hematuria is very common with kidney stones, though its absence does not rule them out.
- "Are you having any pain or burning when you urinate (dysuria)? Increased frequency or urgency of urination?"
- Why: These symptoms point towards a urinary tract infection (UTI) or cystitis, which can sometimes present with flank pain, or a UTI complicating a stone.
- "Have you experienced any vomiting (not just nausea)?"
- Why: Vomiting can accompany severe pain from various causes, including renal colic, but also pancreatitis or other acute abdominal conditions.
- "Have your bowel habits changed recently (constipation, diarrhea, abdominal distension)?"
- Why: To rule out gastrointestinal causes of flank pain, such as diverticulitis, appendicitis (if atypical presentation), or bowel obstruction.
- "Have you had any vaginal discharge, abnormal bleeding, or missed periods?"
- Why: To rule out gynecological causes in a female patient, such as ectopic pregnancy, ovarian torsion, or pelvic inflammatory disease (PID).
- "Have you had any recent injury to your back or side?"
- Why: To assess for musculoskeletal injury as a cause of pain.
Medical History:
- "Do you have a history of kidney stones?"
- Why: A strong predictor of recurrence.