EMR Assessment and Handoff Report for a Patient with Suspected Kidney Stones

QUESTION

Kidney stones, or tiny clumps of minerals that can form inside the kidneys, potentially block the kidneys’ ability to get rid of urine. And if these stones move further into the urinary system, they cause a huge amount of pain.

The thing about kidney stones is that anyone can get them. In fact, doctors estimate that one in 10 people will have a kidney stone at some time in their life. Because few people anticipate having this kind of emergency, it is up to the EMR not only to assess the patient but also to keep them calm during a kidney stone episode. Using their knowledge of the genitourinary system and following the indicators that present themselves, EMRs may be able to home in on the possible issue that their patient is having.

It is important to be able to assess and manage patients who have genitourinary emergencies, but it is also important to be able to convey this information to Emergency Medical Services clearly when they arrive on the scene. Using your text or reputable online sources, research the signs and symptoms displayed by a patient suffering from kidney stones. What is the onset usually like? What might a patient’s vitals look like?

Once you have conducted your research, imagine that you are an EMR called to check on a patient who has a suspected kidney stone. Map out the steps you would take to assess your patient, what results you might expect to find, and the information that you will need to pass along to EMS when they arrive.

Now that you have created your fictitious case study, record yourself providing an oral handoff report to arriving EMS about your patient. Employ your handoff report to demonstrate how you have assessed and managed the patient’s issue. Remember to use the acronym SBAR to create a clear handoff report.

SBAR

• Situation
• Background
• Assessment
• Recommendations

ANSWER

EMR Assessment and Handoff Report for a Patient with Suspected Kidney Stones

Introduction

As an Emergency Medical Responder (EMR), it is essential to be knowledgeable about genitourinary emergencies, such as kidney stones, which can cause excruciating pain and discomfort. This case study outlines the steps an EMR would take to assess and manage a patient with suspected kidney stones and provides an oral handoff report to arriving EMS, utilizing the SBAR communication technique.

Case Study: Assessing a Patient with Suspected Kidney Stones

Situation

I have been called to assess a patient experiencing severe abdominal and flank pain. The patient has no known history of kidney stones or genitourinary issues, and the pain has been increasing in intensity over the past hour.

Background

The patient is a 45-year-old female with no known allergies and a past medical history of mild hypertension, managed with medication. She denies any recent trauma or illness and reports drinking sufficient water throughout the day. The patient is currently at her workplace and is anxious and visibly distressed due to the pain.

Assessment

Upon arrival at the scene, I approach the patient calmly and introduce myself as an EMR. I assess her level of consciousness and vital signs, which include a heart rate of 100 beats per minute, blood pressure of 150/90 mmHg, respiratory rate of 20 breaths per minute, and a temperature of 37.2°C (99°F). The patient is experiencing severe pain in her right flank, radiating towards her lower abdomen. She describes the pain as sharp and intermittent.

As per the patient’s presentation and symptomatology, kidney stones are suspected. I inquire about any history of kidney stones or urinary tract infections in the past. The patient denies any relevant medical history but reports experiencing similar, though milder, episodes of flank pain in the past.

Recommendations

Based on my assessment, I recommend providing pain relief to the patient, as her pain appears to be severe. As kidney stones can be very painful, I decide to administer 1 gram of intravenous acetaminophen, as per my medical protocol.

I will also ensure that the patient remains well-hydrated by encouraging her to drink water to help pass the stone, if indeed it is a kidney stone. Additionally, I will observe the patient’s vital signs and assess for any changes or worsening of symptoms.

Handoff Report to EMS (Using SBAR)

Situation

I am an EMR at the scene of a 45-year-old female patient who is experiencing severe right flank pain, which she describes as sharp and intermittent. The patient denies any known history of kidney stones but reports experiencing milder episodes of similar pain in the past.

Background

The patient has mild hypertension, managed with medication. She has no known allergies and denies any recent trauma or illness. Her vital signs are heart rate 100 bpm, blood pressure 150/90 mmHg, respiratory rate 20 breaths per minute, and temperature 37.2°C (99°F).

Assessment

The patient appears anxious and distressed due to the pain, which has been increasing over the past hour. The pain is located in her right flank, radiating towards her lower abdomen. The patient has no known history of kidney stones or urinary tract infections.

Recommendations

I administered 1 gram of intravenous acetaminophen to provide pain relief. I will monitor the patient’s vital signs and assess for any changes or worsening of symptoms. Encourage the patient to stay well-hydrated to help pass the stone, if kidney stones are confirmed.

Conclusion

Assessing and managing a patient with suspected kidney stones requires careful evaluation and prompt pain relief. As an EMR, utilizing the SBAR communication technique ensures a clear and concise handoff report to arriving EMS, facilitating seamless continuity of care for the patient.