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Surg HPI

IDENTIFICATION:   Z.M.B.                                 

Sex:       M              Race: Hispanic        Nationality:  US          Age:     59            Marital status: Single

Address:                                       Religion:                               PCD:

Informant: self                                    Reliability: Reliable                              Referral: self

CC: RLQ and R flank pain + nausea/vomiting since yesterday 8pm.

ZMB is a 59 y/o M w a PMH of HTN, CAD s/p 1 cardiac stent placement in 4/2020 on Aspirin, asthma, s/p stroke about 2 yrs ago, MVA 10 years ago and lithotripsy 20+ yrs ago presented to ED today with a c/o RLQ and R flank pain associated with nausea and vomiting since yesterday 8pm. He states he wasn’t doing anything specific when it started and describes it as starting in his RLQ but now it’s mostly R flank intermittent sharp stabbing 10/10 about 5 min on 5 min off, radiating down to his scrotum. The pain was also associated with nausea and about 7 episodes of emesis, 3 today, about 1/3 cup each, unable to describe consistency but denies noting any blood in the vomit. Patient said pain got slightly relieved when he drank some water yesterday but then it came back preventing him from sleep which prompted his visit to ED. At the ED was given LR, Zofran, Toradol and Morphine which helped relieve the pain to 3/10 and relieved the nausea. Patient had lithotripsy about 20+ prior to which he had similar symptoms. He denies taking anything for the pain at home. He states he noticed he has been making less urine and the urine became brown in color within the past few days, denies any burning on urination, hesitancy, dribbling, urgency, or incomplete bladder emptying. Denies loss of appetite, diarrhea, or constipation. Last BM yesterday, normal. Last urination this morning, tea colored urine. Patient admits to feeling “his heart racing” but denies any SOB or chest pain. Denies any fever, chills, cough, headache, or dizziness. Denies being sexually active within the past 6 month and denies any discharge from penis. Denies history of current trauma to a torso, fall or extensive straining/exertion.

PMH:

  • HTN on meds
  • CAD s/p 1 stent placement 4/2020 (NYPQ)
  • Asthma “long time ago”, denies current inhaler use
  • Stroke 2 years ago with right side deficits, states it’s fully resolved after he was hospitalized at NYPQ
  • MVA with head trauma s/p abdominal surgery 10 years ago, was hospitalized at Elmhurst, unable to elaborate on further details
  • Lithotripsy 20+ years ago

PSH

  • LAD stent placement 4/2020 (NYPQ)
  • Lithotripsy
  • MVA 10 years ago with abdominal surgery but does not recall what exactly was done (Elmhurst hospital)

Social

ZMB is a single male who lives at home with his mother, sister and her son. Independent in ADLs. Ambulates with a cane due to right side weakness. States he used to smoke 2 cigarettes a day for about 10 years but quit 2 years ago. Denies use of alcohol, caffeine, nicotine products or any illicit substances. Denies being sexually active within the past 6 months.

Meds:

  • Aspirin 81mg 1/day
  • Losartan/HCTZ 100/25 1/day
  • Amlodipine 10 mg 1/day

Allergies: none known

ROS:

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies any headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes: Denies use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, pruritus

 Ears: Denies deafness, pain, discharge, tinnitus, hearing aids use

Nose/Sinuses: Denies discharge, epistaxis, obstruction

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures use

Neck: Denies any localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Denies any chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Admits to abdominal pain, nausea and vomiting as per HPI; denies changes in appetite, intolerance to foods, dysphagia, flatulence, eructation, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool

Genitourinary: Admits to decreased urine output and change in color as per HPI; denies any frequency, incontinence, dysuria, nocturia, urgency, oliguria, polyuria; Denies hesitancy, dribbling. Does not have a urology follow up.

Musculoskeletal system: Denies any muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular system: Denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement

Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous system: Admits to asymmetric right sided weakness; denies any seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, change in cognition/mental status/memory,

Psychiatric: Denies depression/sadness (Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder

Physical Exam:

General: Cooperative well developed male in obvious discomfort, tossing and turning.

Alert, oriented to person, thinks it’s September, unable to recollect a date and states he does not know where we are. Of note, patient has been given 2 mg of Morphine prior to writer’s evaluation.

Vitals:

  • T: 37.4C, oral
  • HR: 90 BPM, regular
  • RR: 22/min, unlabored
  • BP: 153/88 RA, supine
  • O2SAT: 94% room air
  • Skin: warm & moist, good turgor. Dry lips, Nonicteric.
  • Head: non-tender to palpation throughout; no ecchymoses no edema
  • Eyes: PERRL; symmetrical OU; no evidence of strabismus, exophthalmos, or ptosis; sclera white, conjunctiva & cornea clear.  
  • Ears: Symmetrical and normal size.  No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU.
  • Nose and sinuses: Symmetrical / no masses / lesions / deformities / trauma / discharge.
  • Throat: No gross deformities noted in mouth, dentition, and oropharynx. Throat non-injected, no exudates, uvula midline.
  • Neck: Trachea midline.  No masses; lesions; scars or pulsations noted.  Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; no bruits noted bilaterally, no palpable adenopathy noted.
  • Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.
  • Chest: Symmetrical, no deformities, no evidence of trauma. No paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1. Non-tender to palpation.
  • Lungs: Chest expansion symmetrical. Clear to auscultation bilaterally. No adventitious sounds. No increased work of breathing noted.
  • Heart: Regular rate and rhythm; S1 and S1 with no murmurs or gallops, No splitting of S2 or friction rubs appreciated.
  • Abdomen: A large well healed scar noted from upper epigastrium to umbilicus. A dry dark brown rash with scales noted in suprapubic area. Bowel sounds noted in all four quadrants. Soft, non-distended, tender to palpation of right flank, with guarding. No aortic/renal/iliac or femoral bruits appreciated. Unable to appreciate McBurney’s point tenderness since patient is tender allover right flank and RLQ. Negative Proas and Obturator. Negative Roving’s. Negative rebound tenderness. Positive CVA tenderness on the right.
  • GU: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted
  • Peripheral Vascular:  Small 3 x 3 cm telangiectasia noted on medial malleolus of RLE. The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, No stasis changes or ulcerations noted. No edema noted.
  • MSK:No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No evidence of spinal deformities.
  • Neuro: Alert. Normal speech, normal tone, normal gait. CN II – XII grossly intact. No nystagmus. Right sided UE and LE muscle strength 4/5, left 5/5 in all four directions.
  • Psych: Normal mood and behavior

DDX:

Not to miss:

  • Mesenteric Ischemia
  • Testicular torsion: unlikely (no history of straining and unremarkable pelvic exam)
  • Aortic Aneurysm/dissection – likely due to age and Hx of smoking and HTN

Most likely:

  • Renal calculi: likely due to previous history, presentation and positive CVA tenderness
  • Bowel obstruction: possible due to previous bowel instrumentation; unlikely due to patient reporting normal BMs but could be early presentation
  • Appendicitis: likely due to location of pain but unlikely due to absence of anorexia

Less likely:

  • Inguinal/femoral hernia
  • Colon cancer
  • Meckel’s diverticulitis
  • Trauma/MSK pain
  • Renal cell carcinoma

Table

Description automatically generated with medium confidence
Relevant labs and imaging:

A screenshot of a computer

Description automatically generated with medium confidence

~ ABD CT w/o contrast reading:

CLINICAL INDICATION: R10.31: Right lower quadrant pain
 
TECHNIQUE: Thin section images through the abdomen and pelvis were
obtained. Multiplanar reformatted images were also obtained and
evaluated.
 
Intravenous contrast was administered. 96 cc of Omnipaque 300 was
given intravenously without adverse reaction.
 
This CT exam was performed using one or more of the following dose
reduction techniques: Automated exposure control, adjustment of the mA
and/or kV according to patient size, or use of iterative
reconstruction technique.
 
COMPARISON: None.
 
FINDINGS:
 
LOWER CHEST: Unremarkable.
 
LIVER: 5 mm hypodense focus in segment 3 of the liver (series 2 image
24) anteriorly is too small to characterize but may reflect a small
cyst or hemangioma in the absence of hepatic venous factors or history
of malignancy.  
 
SPLEEN: Unremarkable.  
 
PANCREAS: Unremarkable.
 
GALLBLADDER/BILIARY TREE: Unremarkable.    
 
ADRENALS: Unremarkable.  
 
KIDNEYS: At least 7 nonobstructing right renal calculi measuring 2 to
3 mm. At least 2 nonobstructing left renal calculi measuring up to 3
mm. No left hydronephrosis. Normal left renal enhancement.
 
Moderate right hydroureteronephrosis secondary to 2 adjacent
obstructing calculi at the right ureterovesicular junction each
measuring up to 4 mm. There is delayed right renal enhancement
secondary to the obstruction. There is moderate right perinephric
edema.

 
LYMPH NODES/RETROPERITONEUM: Unremarkable.
 
VASCULATURE: Scattered vascular calcifications. Proximal superior
mesenteric artery is patent.    
 
BOWEL/MESENTERY: Prominent right colonic stool and prominent stool in
the distal ileum suggestive of constipation. Normal appendix. No
evidence of acute appendicitis, obstruction, or pneumoperitoneum.  
 
URINARY BLADDER: Focal wall thickening of the anterior bladder with
both solid and cystic components measuring up to 1.6 x 1.7 x 2.2 cm.
 
PELVIC VISCERA: Enlarged prostate gland measuring 6 cm in transverse
diameter.  
 
ASCITES: None.
 
SOFT TISSUES/BONES: Small fat-containing right inguinal hernia.
Nonspecific but nonaggressive appearing 1.4 cm lucent lesion with
well-defined sclerotic rim in the right iliac bone. Mild degenerative
changes of the spine.    
 
 
IMPRESSION:
 
Moderate right hydroureteronephrosis secondary to 2 adjacent
obstructing calculi at the right ureterovesicular junction each
measuring up to 4 mm.

 
Multiple nonobstructing intrarenal calculi measuring 2 to 3 mm. No
left hydronephrosis.
 
Right-sided constipation.
 
Focal anterior urinary bladder wall thickening containing solid and
cystic component suspicious for a urinary bladder wall mass. Follow-up
cystoscopy is recommended.

 
Enlarged prostate gland.  

Assessment:

59 y/o M with obstructing ureteral stones 4mm x 2 with hydronephrosis in right UVJ. Afebrile, mild leukocytosis to 12.26. Admit to Urology due to intractable pain and obstructing stone for plan for cystoscopy with right ureteral stent placement today. Strict NPO except meds with small sips of water.

Plan:

  • Preop checklist: Labs, Coags, T&S, Covid swab, EKG, CXR, consent (patient gave verbal consent), OR booking, medical clearance
  • Strict I&O, vitals every 6 hours, trend Lactate
  • Continue home meds
  • Neuro: pain control PRN (alternate Tylenol 650 mg (no more than 2000mg/day), Toradol IM 15mg, oxycodone 5 mg, Morphine injection 2 mg)
  • GI: Pantoprazole (Protonix) tab 40mg 1/day; Zofran 8mg tab PRN
  • GU: Follow up Urine culture; Tamsulosin 0.4mg 1/day, recommend aggressive IV hydration with LR, strain all urine
  • ID: Cefazolin IVBP 1g in 50 ml 
  • Encourage early ambulation and incentive spirometry postop
  • Patient education on importance of oral hydration at home and importance of recovering the stones in order to make dietary choices helpful for preventing stone recurrence.

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