EM H&P 2

Chief Complaint
“Right-sided flank pain” x 3 days

History of Present Illness
71-year-old female with a past medical history of hypertension, diabetes, hypothyroidism, and a right-sided kidney stone two years ago, presenting with right-sided flank pain for the past three days. The symptoms initially began with a burning sensation upon urination early Sunday morning, which was followed by three episodes of non-bloody, non-bilious emesis. The following day, she started experiencing intermittent sharp pain in her right flank, which she states is worse with urination. She has taken Tylenol for relief but reports minimal improvement in her symptoms.

Today, the patient reports worsening of symptoms, including four additional episodes of non-bloody, non-bilious emesis, prompting her visit to the ED. She describes the flank pain as a constant 5/10 without radiation and is concerned about the possibility of another kidney stone, given her history of a right-sided stone two years ago, though she does not recall any specific interventions at that time.She denies any fever, chills, hematuria, chest pain, shortness of breath, or recent illness.

Past Medical History

  • Hypertension – Controlled with medications
  • Diabetes Mellitus – Type 2, managed with diet and medications
  • Hypothyroidism
  • History of Right-Sided Kidney Stone – Two years ago; no surgical intervention reported

Medications

  • Atenolol 50 mg, PO daily
  • Levothyroxine 88 mcg, PO daily
  • Lisinopril 20 mg, PO daily
  • Farxiga 10 mg 

Past Hospitalizations: 

None

Past Surgical History:  

None

 Allergies

  • No known drug, food, or environmental allergies

Family History

  • Mother: Deceased, 
  • Father: Unknown
  • No known family history of kidney stones, MI, or cancer

Social History

  • Smoking: Never
  • Alcohol: Social use, approximately 1 glass of wine weekly
  • Illicit Drug Use: Denies any past or current use
  • Travel: Denies recent travel
  • Exercise: Occasional walks
  • Diet: Balanced diet, no specific dietary restrictions
  • Caffeine: 1 cup of coffee daily

Review of Systems (ROS)

  • General: Denies fever, chills, weight changes, fatigue, or night sweats
  • Skin: Denies rashes, lesions, or itching
  • HEENT: Denies visual changes, hearing loss, or sore throat
  • Neck: Denies neck pain or stiffness
  • Pulmonary: Denies cough, shortness of breath, or wheezing
  • Cardiovascular: Denies chest pain or palpitations
  • Gastrointestinal: Admits to nausea and 4 episodes of non-bloody, non-bilious emesis ; denies diarrhea or constipation
  • Genitourinary: Admits to burning with urination and right flank pain; denies frequency, urgency, incontinence, or hematuria
  • Musculoskeletal: Denies muscle or joint pain
  • Neurologic: Denies dizziness, headache, or focal weakness
  • Endocrine: Denies heat or cold intolerance
  • Psychiatric: Denies anxiety or depression

Physical Exam

  • Vitals: BP: 138/78 HR: 76 bpm, RR: 18, Temp: 97.7 , SpO2: 97 % on RA
  • General: 71-year-old female in mild distress due to pain, alert and cooperative
  • HEENT: Normocephalic, atraumatic, PERRL, EOM intact
  • Neck: Supple, trachea midline, no cervical lymphadenopathy
  • Heart: Regular rate and rhythm, no murmurs, rubs, or gallops
  • Lungs: Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi
  • Abdomen: Soft, mild suprapubic tenderness and right lateral lower abdominal tenderness; no rebound, guarding, or masses.
  • Genitourinary: No CVA tenderness 
  • Musculoskeletal: Full range of motion, no joint swelling or deformity
  • Neurologic: Alert and oriented x3.

DDX:

Pyelonephritis:Pyelonephritis is the most likely diagnosis due to vomiting, flank pain, and dysuria. Although fever and CVA tenderness are absent, vomiting is a key symptom suggesting an infection.

Urinary Tract Infection: UTI is a possible diagnosis, given the dysuria and flank pain. The absence of fever doesn’t rule it out, especially in older adults.

Nephrolithiasis (Kidney Stone):Given the patient’s history of right-sided kidney stones and current flank pain, nephrolithiasis is a strong possibility. However, the lack of CVA tenderness makes it less likely but not to be ruled out.

Ovarian Cyst:While an ovarian cyst can cause abdominal or flank pain and vomiting, the occurrence of ovarian cysts is less likely in a 71-year-old female

Assessment:

I.H. is a 71-year-old female with a history of hypertension, diabetes, hypothyroidism, and right-sided kidney stones, presenting to the ED with right flank pain for 3 days, along with dysuria and vomiting. Nephrolithiasis is less likely given the absence of CVA tenderness, but due to her history of kidney stones and current symptoms of dysuria, further labs and imaging will be obtained to evaluate the underlying cause.

Labs/Imaging:

  • CBC, BMP, LFTs, Lipase, Urinalysis, Urine Culture.
  • CTAP with IV contrast

Results:

CBC,BMP(glucose 152),LFTs,Lipase all WNL

CTAP with IV contrast: 3 mm non obstructing right renal calculus stone 

ED Course: Lidocaine 4% patch , ketorolac 15 mg

Plan:

# UA consistent with UTI 

  • Start Cefdinir 300 mg, 1 capsule twice a day for  1 week.

Dispo: Patient reports improvement in pain after receiving ketorolac and lidocaine patch.Educated to staying hydrated and completing full course of antibiotics even if she starts to feel better.

  • Advised Patient to follow up with PCP if symptoms do not improve after 2-3 days.  
  • Advised to return to the ED if worsening flank pain, fever, chills, persistent nausea/vomiting, or hematuria