Date: 3/22/2021
History:
Identifying Data:
Name: JP
Sex: female
Date of Birth: 1960
Location: NYPQ hospital
Race: African American
Source of Information: self
Chief Complaint: “I have left sided pain and back pain since Saturday”
HPI:
Ms. JP is a 60 y/o African American female with a past medical history of hyperlipidemia, HTN, DM, and nephrolithiasis with shock wave lithotripsy presents to the ED with a complaint of left sided flank pain and back pain since Saturday at 6 PM. She states the pain was sudden on onset, sharp and non-radiating. She rates the pain as 10/10. She took Tylenol for the pain, but it was not relieved. She admits to one episode of nausea and vomiting on Saturday. She has had hematuria for one week. She denies fever, chills, dysuria, urinary frequency, urinary incontinence, diarrhea or changes in appetite. Patient presents with a CT scan from Main Street Radiology from 2 days ago showing a 5 mm left renal pelvis calculus and 2 mm left lower renal calculus.
Past Medical History: Hyperlipidemia, Hypertension Diabetes, nephrolithiasis, colon cancer in 2009.
Past Surgical History: Hernia repair (2020), Lumpectomy (2010), Colon Resection (2009), Cholecystectomy, Appendectomy (1969).
Family History: Mother Diabetes, hypertension, deceased 75 y/o
Father: Diabetes 80 years old alive and well
Vaccines: Childhood vaccines up to date.
Social History: never smoked, drinks alcohol socially, denies illicit drug use
Sexual History: not sexually active
Allergies: Eggplant (reaction: angioedema), Coconut (reaction: upset stomach), no known drug allergies.
Medications:
Metformin 850 mg oral tablet BID
Rosuvastatin Calcium 10 mg oral tablet QD
Vitamin D3 2,000 units oral tablet QD
Losartan Potassium: 25 mg oral tablet QD
Review of Systems:
General: Denies night sweats, fatigue, weakness and recent weight gain or loss.
Skin, Hair, Nails: Denies change in texture, excessive dryness, sweating, rashes/moles, discolorations, or pruritis.
Head: Denies headache, vertigo, head trauma, loss of consciousness or coma.
Eyes: Admits to use of glasses for reading and distance. Admits to dry eyes. Denies visual disturbances, fatigue, lacrimation, photophobia or pruritus. Last eye exam 2 years ago.
Ears: Denies deafness, changes in hearing, pain, discharge, tinnitus, or use of hearing aids.
Nose/sinuses: Denies discharge, epistaxis or obstruction.
Mouth and throat: Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice changes, dentures. Patient doesn’t know when her last dental exam was.
Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast: Denies lumps, nipple discharge or pain. Last mammogram unknown.
Pulmonary System: Denies dyspnea, shortness of breath, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.
Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, or syncope.
Gastrointestinal System: Denies changes in appetite, intolerance to foods, dysphagia, pyrosis, excessive flatulence, eructation, jaundice, constipation, rectal bleeding, or hematochezia.
Genitourinary: Denies nocturia, urgency, oliguria or polyuria.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral Vascular System: Denies intermittent claudication coldness, varicose veins, peripheral edema or color change.
Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE.
Endocrine System: Denies polydipsia, polyphagia, polyuria, heat or cold intolerance, goiter or hirsutism.
Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesia, hyperesthesia), ataxia, loss of strength, changes in cognition/mental status/memory or weakness.
Psychiatric: Denies Anxiety, loss of interest in previously enjoyed activities, or depression.
Physical:
Vitals:
BP: 119/79
HR: 72
Sp O2: 96% room air
Temperature: 37 degrees Celsius (oral)
RR: 16
Height: 165 cm
Weight: 70.3
BMI: 25.8 kg/m2
General: Alert, awake and oriented x3. Overweight.
Skin: warm and moist, good turgor, non-icteric. No lesions, masses or tattoos. One large midline scar and four small surgical scars noted on abdomen in all quadrants.
Hair: Average distribution and quantity.
Nails: No clubbing, capillary refill <2 seconds throughout.
Head: Normocephalic, atraumatic, no deformities, non-tender to palpation throughout.
Eyes: Symmetrical. Eyebrows and eyelashes even distribution, sclera white, conjunctiva clear. PERRLA. Visual fields full OU.
Ears: Symmetrical. No lesions, masses or trauma on external ears. No discharge/foreign bodies, tympanic membrane pearly white/intact with cone of light at 5 o’clock position AD and 7 o’clock AS. Auditory acuity intact to whispered voice AU.
Nose: No masses, lesions, trauma. Nares patent bilaterally. No discharge noted.
Sinuses: non-tender to palpation over frontal and maxillary sinuses.
Mouth:
Lips: pink moist, no cyanosis or lesions.
Mucosa: pink, well hydrated, no masses or lesions.
Palate: pink, well hydrated.
Teeth: Good dentition.
Gingivae: Pink, moist, no hyperplasia, masses lesions.
Tongue: Pink, no masses, lesions or deviation.
Oropharynx: Well hydrated, no exudate, masses, lesions, foreign bodies. Tonsils present without exudate. Uvula pink and rises symmetrical with phonation.
Neck: Trachea midline. Non-tender to palpation, 2+ carotid pulses.
Thyroid: Non—tender, no nodules, or enlargement.
Lungs: Respirations unlabored, chest rises symmetrically, clear to auscultation in all lung fields. No adventitious lung sounds.
Heart: Regular rate and rhythm S1 and S2 present. No murmurs.
Abdomen: Non-distended. Midline scar and multiple small scars in all four quadrants. Normoactive bowel sounds present in all four quadrants. Non-tender to palpation. No guarding or rebound tenderness. CVA tenderness present on the left side.
Genitalia: Patient refused exam
Rectal: Patient refused exam
Muscular skeletal: Full active range of motion and strength in all extremities.
Labs:
LABS (3/22/2021):
139 | 105 | 22.4
——————–< 106 Ca: 9.2 Mg: 2.3 Anion Gap: 10 [03/22 @ 23:37]
4.4 | 24 | 1.40
WBC: 9.87 / Hb: 11.1 (MCV: 84.2) / Hct: 37.4 / Plt: 272 [03/22 @ 23:37]
— Diff: N:62.7% L:25.50% Mo:9.5%
PT: 12.5 / PTT: 28.4 / INR: 1.04 [03/22 @ 23:37]
UA — Appearance: Yellow / Clear, s.g.:1.014, pH: 5.5, glucose: Negative, protein: Negative, ketones: Negative, blood: Small, glucose: Negative, nitrite: Negative, leuk est: Negative
UA (micro) — RBC: 2, WBC: 2, Bacteria: Negative [03/22 @ 23:37]
BUN/Creatinine Ratio: 16 [03/22 @ 23:37]
Higher GFR estimate (approximate): 47 mL/min/1.73 m2 [03/22 @ 23:37]
Lower GFR estimate (approximate): 41 mL/min/1.73 m2 [03/22 @ 23:37]
Hyaline Cast: 0 /LPF [03/22 @ 23:37]
Squamous Epith Cells: 1 /HPF [03/22 @ 23:37]
Urine Urobilinogen: 0.2 mg/dL [03/22 @ 23:37]
Urine pH: 5.5 [03/22 @ 23:37]
Urine Bilirubin: Negative [03/22 @ 23:37]
Absolute NRBC: 0.00 x10(3)/uL [03/22 @ 23:37]
Nucleated RBC Auto: 0.00 /100 WBC’s [03/22 @ 23:37]
Mean Platelet Volume: 9.6 fL [03/22 @ 23:37]
RDW-CV: 15.1 % [03/22 @ 23:37]
Mean Cell Hemoglobin Concentration: 29.7 g/dL [03/22 @ 23:37]
Mean Cell Hemoglobin: 25.0 pg [03/22 @ 23:37]
Red Blood Cell Count: 4.44 M/uL [03/22 @ 23:37]
Imm Gran Abs.: 0.03 [03/22 @ 23:37]
Basophil Absolute Number: 0.03 K/uL [03/22 @ 23:37]
Eosinophil Abs #: 0.17 K/uL [03/22 @ 23:37]
Monocyte Absolute Number: 0.94 K/uL [03/22 @ 23:37]
Lymph Absolute # (Westchester): 2.52 K/uL [03/22 @ 23:37]
Absolute Neutrophil Count: 6.18 K/uL [03/22 @ 23:37]
Imm Gran %: 0.30 % [03/22 @ 23:37]
Basophil percent auto: 0.30 % [03/22 @ 23:37]
Eosinophil Automated: 1.70 % [03/22 @ 23:37]
Lactate WB Ven: 1.4 mmol/L [03/22 @ 23:37]
Assessment:
Ms. JP is a 60 y/o African American female with a past medical history of hyperlipidemia, HTN, DM, and nephrolithiasis with a new 5 mm left renal pelvis calculus and 2 mm left distal lower renal calculus.
Plan:
Admit to Urology
Morphine for pain control
Prophylaxis Ancef
Flomax
NPO after midnight.
Left stent with possible ureteroscopy with laser 3/23/21
Preop labs CXR, EKG, COVID
Medical Clearance
Strain all urine
Patient Education:
Kidney stones are little stones formed by salts and minerals that build up and harden in the urine formed inside the kidney. They get carried out by the body when you urinate, but sometimes they get stuck. If they get stuck this causes a lot of pain. You have two stones a 5 mm stone and a 2 mm stone. You will be given flomax to help relax the muscles so that the stone may pass on its own. We want you to urinate through a special strainer so that if the stone passes with urination you will see it. If you don‘t pass the stone on your own then your urologist will use a scope that will go up your urethra to find the stones and break them up with laser.
DDx:
Uretrolithiasis
Pyelonephritis
UTI
