Med Surg Case Study #39: Joseph Drews

Joseph Drews | 45 years old

Chief Complaint: Joseph Drews presents to the emergency department with severe, sharp pain in his lower back and abdomen, radiating to his groin. He describes the pain as "excruciating" and rates it as 9/10. He also reports nausea and has had one episode of vomiting.

Medical History:

Joseph has a history of recurrent kidney stones, with his last episode occurring two years ago. He has no significant chronic illnesses but does report a family history of kidney stones. Joseph states that he has been drinking less water than usual due to a busy work schedule.

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Nurse's Note:

• Patient is admitted to the emergency department with complaints of severe flank pain radiating to the groin, consistent with renal colic. He appears pale, diaphoretic, and is writhing in pain. He reports that the pain started suddenly while he was at work and has progressively worsened over the past few hours. He denies any fever or chills but reports difficulty urinating due to the pain.

  
  

Vital Signs:

• Blood pressure: 148/88 mmHg

• Heart rate: 104 bpm

• Respiratory rate: 20 breaths/min

• Temperature: 98.8°F (37.1°C)

• SpO2: 98% on room air

Provider's Orders:

• Administer IV Morphine 4 mg once for pain management.

• Administer IV Ondansetron 4 mg Q4 PRN for nausea.

• Start IV fluids: Normal Saline at 100 mL/hr.

• Order a non-contrast CT scan of the abdomen and pelvis to evaluate for kidney stones.

• Monitor urine output and strain all urine for stone analysis.
  

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 The non-contrast CT scan confirmed the presence of a 1.2 cm calculus in the right ureter, causing obstruction and hydronephrosis.

Nurse's Note:

Patient reports some relief after receiving pain medication but continues to experience significant discomfort. He continues to experience nausea and has had one more episode of vomiting. His urine output is reduced, and he has only been able to void a small amount of blood-tinged urine.

Vital Signs

• Blood pressure: 142/84 mmHg

• Heart rate: 98 bpm

• Respiratory rate: 18 breaths/min

• Temperature: 98.7°F (37.1°C)

• SpO2: 99% on room air

Provider's Orders:

• Continue IV fluids: Normal Saline at 100 mL/hr.

• Administer Ketorolac 30 mg IV for additional pain relief, Once

• Schedule the patient for ureteroscopy with possible lithotripsy to remove the stone.

• Continue monitoring urine output and strain all urine.

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Nurses Note: Patient is prepped for ureteroscopy and lithotripsy. He reports feeling more comfortable after the administration of additional pain medication. His pain is now rated as 5/10. The patient is anxious about the upcoming procedure but understands the necessity due to the persistent obstruction and pain. Urine output remains low, and the patient has passed small amounts of blood-tinged urine.

Vital Signs:

• Blood pressure: 138/82 mmHg

• Heart rate: 92 bpm

• Respiratory rate: 16 breaths/min

• Temperature: 98.6°F (37°C)

• SpO2: 98% on room air

Provider's Orders:

• Post-operative orders include

  • Normal Saline at 75 mL/hr

  • IV Morphine 2 mg Q4 PRN

  • Activity as tolerated

    
    

• Educate the patient about post-procedure care, including the possibility of passing stone fragments and the importance of fluid intake.

Follow Up Questions:

Question 1: What is the primary reason Joseph is experiencing such severe pain?

Question 2: Why was a non-contrast CT scan ordered for Joseph?

Question 3: What is the purpose of administering IV fluids to Joseph?

Question 4: Why was ureteroscopy and lithotripsy recommended for Joseph?

Answers to Questions Below

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Answers

Question 1: What is the primary reason Joseph is experiencing such severe pain?

Joseph is experiencing severe pain due to a kidney stone obstructing the right ureter, leading to renal colic. This obstruction causes increased hydrostatic pressure in the renal pelvis and ureter, leading to distention and intense, colicky pain radiating to the groin.

Question 2: Why was a non-contrast CT scan ordered for Joseph?

A non-contrast CT scan was ordered to confirm the presence, size, and location of the kidney stone. This imaging study is the most accurate and efficient way to visualize the urinary tract and identify any obstruction.

Question 3: What is the purpose of administering IV fluids to Joseph?

IV fluids are administered to Joseph for several reasons:

• To maintain hydration and prevent dehydration, which can worsen kidney function.

• To increase urine output and help flush out the kidney stone.

• To support blood pressure and prevent hypotension, which can occur due to pain and fluid loss.

Question 4: Why was ureteroscopy and lithotripsy recommended for Joseph?

Ureteroscopy and lithotripsy were recommended for Joseph because the kidney stone is causing significant pain and obstruction. Ureteroscopy allows the physician to directly visualize the ureter and remove the stone using a small instrument. Lithotripsy, if needed, can be used to break up the stone into smaller pieces for easier removal.

Stones larger than 1 cm typically require intervention for removal, as they are unlikely to pass spontaneously and can lead to complications such as infection or kidney damage.

Med Surg Case Study #39: Joseph Drews