Case Study: Sudden Severe Pain

A new case study in which the patient, D.C., a 52-year-old, white, married college professor wakes up to severe and intensifying pain. Though the coronavirus pandemic is sweeping the nation, his pain is so severe his wife drives him to the ER.

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Case Study: Sudden Severe Pain

History of Present Illness:

D. C., a 52-year-old, married, white college professor, woke up to severe and increasing pain in his right flank this morning. He came to the ER in acute distress with pallor, diaphoresis and significant anxiety (over his pain and over having to come to ER during coronavirus pandemic). He was in so much pain, he couldn't sit still on the bed in the ER but continued to move around, constantly repositioning himself, groaning in pain and grimacing. He even vomited twice from the pain. He was given promethazine hydrochloride IV for nausea by the nurse. Due to his allergy to meperidine he was also given morphine IV for pain.

Okay super sleuths, what are all the possible reasons for right flank pain? As always, imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!

A few other fun questions to think about:

What is the pathophysiology behind pallor and diaphoresis?

How does promethazine relieve nausea and vomiting?

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Labs: CMP; Liver panel; amylase & lipase; CBC

Vital Signs?

Any urinary symptoms? Any aggravating factors such as fatty foods?

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Specializes in Education, Informatics, Patient Safety.
10 minutes ago, 2Ask said:

Labs: CMP; Liver panel; amylase & lipase; CBC

Vital Signs?

Any urinary symptoms? Any aggravating factors such as fatty foods?

Good questions! More to come next week. No fatty foods- I’ll give you that one now.

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A full set of vital signs and PMH please. Also any imaging of KUB like US or Fluoro?

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Specializes in Education, Informatics, Patient Safety.
54 minutes ago, DextersDisciple said:

A full set of vital signs and PMH please. Also any imaging of KUB like US or Fluoro?

You will definitely get those next week. Thank you!

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Specializes in EMT/CPT/Outpatient Care/LTC.

Where and what types of foods have you eaten in past 48 hours? Last BM? Is pain localized to R Flank? Colonoscopy/GI records? History of GI problems?

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Specializes in OR.
ShootingPains.jpg
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Specializes in Education, Informatics, Patient Safety.
8 minutes ago, 11blade said:

ShootingPains.jpg

This made me laugh so hard I got a shooting pain in my side!

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Any blood in the urine, difficulty voiding, change in urine output, any diarrhea, pain at tip of member?

Urinalysis results?

Sometimes paleness and sudden excessive sweating/ diaphoresis can be caused by an emotional state like panic due to severe pain.

Promethazine is in a class of medications called phenothiazines. It works inhibiting dopamine, muscarinic and histamine (H1) receptors generally in the vomiting center and in the stomach.

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Specializes in Education, Informatics, Patient Safety.

First, an answer to my questions:

What is the pathophysiology behind pallor and diaphoresis?

Pain stimulates the fight or flight response which causes the release of catecholamines. Adrenaline has a variety of effects including enhancing perspiration (or diaphoresis, which prepares the body for the increase in temperature associated with fleeing/fighting), dilation of the pupils (which increases light sensitivity, but reduces acuity), dry mouth (gastric juices and saliva production decreases because blood flow to the digestive system is decreased), enhanced smell and hearing, and a cool, pale skin.

How does promethazine relieve nausea and vomiting?

Promethazine is a phenothiazine (antipsychotic) derivative with very weak dopamine receptor antagonism, that also blocks H1 receptors. It produces clinically useful anti-emetic and sedative effects.

And now on to the case...

Past Medical History:

  • Tonsillectomy for chronic earache and sore throat, age 6
  • Zenker diverticulum, age 48
  • Renal stones: ages 35, 44, 50 (all passed spontaneously)
  • IgG immunodeficiency disorder, secondary to Non-Hodgkin's T cell-rich B-cell lymphoma, age 48, treated with 6 monthly sessions of CHOP, currently in remission.

Social History:

Does not smoke or drink, runs 20-30 miles per week. Training for marathon and has increased mileage on his runs. States, “I keep forgetting to bring enough water on my runs.”

Medications:

  • Rabeprazole for acid reflux for Zenker diverticulum (ZD)
  • Gamma globulin infusions once every 5-6 weeks for immunodeficiency
  • Multivitamin daily
  • Chewable 500-mg vitamin C tablet daily to boost immune response. Increased to 1000-mg daily since threat of coronavirus has entered the US.

Allergies: Meperidine

Review of Systems: only abnormal values presented

  • Skin: Pale, cool, and clammy without lesions or bruises
  • HEENT: Difficulty swallowing related to ZD

Vital signs:

  • BP 132/84 sitting, RA
  • HR 88
  • RR 17
  • T 98.5oF
  • HT 6’
  • WT 190 lbs

Laboratory Test Results:

  • Na 139 meg/L
  • K 4.2 meq/L
  • Cl 103
  • Mg 2.0 mg/dL
  • PO4 2.8 mg/dL
  • Ca 10.1 mg/dL
  • Uric acid 6.2 mg/dL

I hope there's something in there to help you with your diagnosis - more to come in a few days!

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Specializes in Education, Informatics, Patient Safety.
On 4/11/2020 at 4:44 PM, NRSKarenRN said:

Any blood in the urine, difficulty voiding, change in urine output, any diarrhea, pain at tip of member?

Urinalysis results?

Sometimes paleness and sudden excessive sweating/ diaphoresis can be caused by an emotional state like panic due to severe pain.

Promethazine is in a class of medications called phenothiazines. It works inhibiting dopamine, muscarinic and histamine (H1) receptors generally in the vomiting center and in the stomach.

Thanks for answering my questions - I'll get you the UA by the end of the week. No blood in the urine, no difficulty voiding, no diarrhea, no pain at tip of member. He says, "My urine has been darker the last few days."

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Specializes in Education, Informatics, Patient Safety.
On 4/11/2020 at 12:40 PM, southernemtphleb said:

Where and what types of foods have you eaten in past 48 hours? Last BM? Is pain localized to R Flank? Colonoscopy/GI records? History of GI problems?

He's eaten his normal diet: oatmeal and yogurt for breakfast, a sandwich for lunch and fish and salad for dinner one night and pizza the other. Last BM was the evening before admission. Pain is localized to R flank. I just posted his medical history - check it out! Thanks so much for participating.

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