H&P #2
Chief Complaint:
“Really bad stabbing pain on my right side ”
History of Present Illness:(01/16/2024)
29 year old female with no significant pmhx presented to the ED 4 hours ago due to severe sharp stabbing right flank pain , nausea and nonbilious nonbloody vomiting for the past 12 hours. Pt reports pain does not radiate and is currently at an 9/10 on pain scale.Pt was seen in Jamaica Hospital (01/15/2023) ER for PNA and UTI in which she was given antibiotics and pain control, discharged in stable condition. In the same visit, pt also reports being diagnosed with a 5mm right UVJ, 6mm intrarenal stone and moderate right hydronephrosis. Pt was discharged with MET (Meloxicam, Cefdinir, Fluconazole and flomax) and told to return to the ED if symptoms worsen(fever develops or excruciating pain), PT came in today due to worsening right flank pain not relieved with pain meds Pt also admits to persistent dysuria, hematuria, chills and inability to tolerate p.o intake. Pt denies any fever, history of kidney stones, headaches, chest pain, SOB, lightheadedness, or trauma.
Past Medical History:
No significant Pmhx.
Past Surgical History:
- Pa
Medications:
(See HPI for current medications)
Denies any other supplements, herbals, and prescribed/OTC medications.
Allergies:
- No known drug allergies
- No known food allergies
- No known environmental allergies
Family History:
- No known significant family history
Social History:
- Single,Teachers Aid living with family in Jamaica, Queens.
- Endorses sexual activity
- Endorses normal balanced diet.
- Endorses going to gym(2 hours daily). ADLs/IADLs intact and fully independent.
- Pt occasionally drinks(once a week),denies smoking and illicit drug use
Review of Systems:(01/17/2024)
- General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
- Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
- Head: Denies headaches, head trauma, vertigo.
- Eyes: Denies vision loss ,eyelid swelling, pruritus, photophobia, lacrimation.
- Ears: Denies ear pain, deafness, discharge, tinnitus.
- Nose: Denies epistaxis, discharge, congestion
- Mouth/throat: Denies sore throat, voice changes, bleeding gums.
- Neck: Denies localized swelling/lumps, stiffness/decreased ROM
- Breast: Denies lumps, nipple discharge, pain.
- Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
- Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, syncope, palpitations, or known heart murmur.
- Gastrointestinal: Admits to 1 episode of nonbloody nonbilious vomiting in the past 12 hours. Denies,diarrhea constipation, abdominal pain, decreased flatulence. Denies, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, hematochezia, melena, hematemesis.
- Genitourinary: Admits to some discomfort while urinating and some hematuria for past 24 hours.Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria,, incontinence, flank pain, history of hernias.
- Musculoskeletal: Admits to right sided flank pain, better than yesterday, currently 4/10. . Denies arthritis, muscle pain, deformity or swelling, redness.
- Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
- Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
- Hematologic:Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
- Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
- Psychiatric: Denies depression/sadness, anxiety, OCD.
Physical Exam:(01/17)
Vitals:
- BP: 124/72 (supine)
- HR: 50 (regular)
- RR: 18 (unlabored)
- T: 36.7 C (oral)
- O2: 98% (room air)
General: Neatly groomed, looks her age, alert and oriented x 3,
Skin: Warm & moist; non-icteric; no rashes some lesions
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Eyes: Sclera white, cornea clear, conjunctiva pink. PERRLA. Visual fields full OU. EOM intact, no nystagmus.
Ears: No lesions, trauma, discharge noted to external ear.
Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.
Sinus: Non-tender to palpation.
Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.
Neck: Trachea midline. Supple and non-tender to palpation. No cervical lymphadenopathy noted.
Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.
Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or wheezing
Abdomen: Right CVAT, RLQ tenderness upon palpating. Abdomen flat and symmetric with no striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No guarding or rebound noted. No hepatosplenomegaly to palpation,
Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally.
Reflexes: Intact, 2+ brachioradialis, triceps, biceps, patellar, Achilles reflexes bilaterally.
Absent Babinski. No clonus.
Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in brachial, radial, DP and PT arteries. No bruits noted, clubbing, cyanosis, edema, stasis changes, or ulcerations bilaterally.
Female GU exam: voiding, other wise not exposed
Differential Diagnosis:
- Nephrolithiasis
- Pyelonephritis
- Ovarian Cyst
Workup:
- Labs:
| Latest Reference Range & Units | 01/15/24 1 | 01/17/24 | |
| WBC COUNT (include numbers in presentation) | 4.80 – 10.80 x10(3)/uL | 16.21(H) | 9.52 |
| HEMOGLOBIN | 11.7 – 15.3 g/dL | 14.2 | 11.2 |
| HEMATOCRIT | 35.0 – 45.0 % | 41.5 | 33.6 |
| MEAN CORPUSCULAR VOL (MCV) | 78.0 – 100.0 fL | 89.2 | 93.6 |
| MEAN CORP HGB (MCH) | 26.0 – 34.0 pg | 30.5 | 31.6 |
| MEAN CORP HGB CONC (MCHC) | 31.0 – 37.0 g/dL | 34.2 | 33.3 |
| RED CELL DIST WIDTH (RDW) | 11.5 – 14.5 % | 12.5 | 12.6 |
| RED BLOOD CELL COUNT | 4.50 – 5.20 x10(6)/uL | 4.65 | 3.59 |
| NUCLEATED RBC AUTO | 0.00 – 0.00 /100 WBC’s | 0.00 | 0.00 |
| NUCLEATED RBC ABSOLUTE | 0.00 – 0.00 x10(3)/uL | 0.00 | 0.00 |
| PLATELET COUNT, AUTO | 150 – 400 x10(3)/uL | 255 | 211 |
| MEAN PLATELET VOLUME, AUTO | 8.0 – 11.0 fL | 12.4(H) | 11.2(H) |
| NEUTROPHILS %, AUTO | 37.0 – 80.0 % | 84.7 (H) | 52.6 |
| NEUTROPHILS, ABSOLUTE, AUTO | 1.80 – 8.50 x10(3)/uL | 13.75 (H) | 5.01 |
| LYMPHOCYTES %, AUTO | 15.00 – 40.00 % | 9.8 (L) | 33.5 |
| LYMPHOCYTES, ABSOLUTE, AUTO | 0.80 – 3.50 x10(3)/uL | 1.59 | 3.19 |
| MONOCYTES %, AUTO | 3.0 – 10.0 % | 4.4 | 9.7 |
| MONOCYTES, ABSOLUTE, AUTO | 0.20 – 0.90 x10(3)/uL | 0.71 | .92(h) |
| EOSINOPHILS %, AUTO | 0.00 – 5.00 % | 0.10 | 3.40 |
| EOSINOPHILS, ABSOLUTE, AUTO | 0.00 – 0.60 x10(3)/uL | 0.01 | 0.32 |
| BASOPHILS %, AUTO | 0.00 – 1.00 % | 0.40 | 0.50 |
| BASOPHILS ABSOLUTE, AUTO | 0.00 – 0.30 x10(3)/uL | 0.06 | 0.05 |
| IMMATURE GRANULOCYTES % | 0.00 – 1.00 % | 0.60 | 0.30 |
| IMMATURE GRANULOCYTES, ABSOLUTE | 0.00 – 0.10 x10(3)/uL | 0.09 | 0.03 |
| Latest Reference Range & Units | 01/15/24 | 01/17/24 | ||
| APPEARANCE, URINE | Clear | Turbid ! | ||
| COLOR, URINE | Yellow | Yellow | ||
| SPECIFIC GRAVITY, URINE | 1.010 – 1.030 | 1.020 | ||
| BACTERIA, URINE | Negative | Negative | ||
| SQUAMOUS EPITH CELLS, URINE | 0 – 5 /HPF | 4 | ||
| RED BLOOD CELLS, URINE | 0 – 2 /HPF | 24 (H) | ||
| WHITE BLOOD CELLS, URINE | 0 – 3 /HPF | 6 (H) | ||
| YEAST, URINE | None | None | ||
| HYALINE CASTS, URINE | 0 – 7 /LPF | 2 | ||
| PH, URINE | 5 – 8 | 8.5(H) | ||
| PROTEIN, URINE | Negative/Tracemg/dL | Trace | ||
| BLOOD, URINE | Negative | Small ! | ||
| GLUCOSE, URINE | Negative | Negative | ||
| KETONES, URINE | Negative mg/dL | 80 ! | ||
| BILIRUBIN, URINE TEST STRIP | Negative | Negative | ||
| UROBILINOGEN URINE (MCNC) | 0.2 mg/dL | 1.0 | ||
| NITRITE, URINE | Negative | Negative | ||
| LEUKOCYTE ESTERASE, URINE | Negative | Small! |
| Latest Reference Range & Units | 01/17/24 | |
| Sodium | 135-145 | 138 |
| Potassium | 3.5-5 | 3.9 |
| Chloride | 95-105 | 101 |
| Carbon Dixoxide | 23-29 | 25 |
| BUN | 6-24 | 11.9 |
| Creatinine | 0.7-1.3 | 0.79 |
| Glucose | 70-100 | 95 |
Imaging
CT of abdomen and pelvis -01/15/2024
Impression:
Obstructing Calculus at the right Ureterovesical junction, .5cm. Resulting moderate right hydronephrosis. Slightly decreased enhancement of the right kidney, may be due to obstruction.
Nonobstructing calculus in the lower right kidney, .6cm
Mild diffuse urinary bladder wall thickening, may be due underdistention versus cystitis.
Coalescent patchy lung opacities/consolidation in the right lower lobe posteriorly. Several small adjacent nodular opacities in the right lower lobe, may be tree-in-bud. Faint tree-in-bud opacities in the left lower lobe posteriorly. Findings may be due to infection/pneumonia in the appropriate clinical setting. After acute symptoms resolve, a follow-up CT chest examination would be helpful to document resolution of the imaging findings and evaluate for an underling lesion
Nodular opacity in the right middle lobe anteriorly, 0.5 cm, may be a lung nodule versus intrapulmonary lymph node, can be monitored on a follow-up CT chest examination
Assessment:
29 y/o F presents to the ED right sided flank pain, nausea/vomiting, hematuria and dysuria for 1 day. She was diagnosed with a UVJ stone yesterday (.5cm in the right UVJ), and today upon second presentation now required admission for further workup.
Pt was admitted by urology for monitoring of kidney stones.Today patient is Afebrile and VSS, not in any acute distress. Positive for right CVAT, denies any other complaints.
Plan:
- Kidney stone
- IV fluids(LR 125 continuous)
- Pain control(IV ketorolac 15 mg) Q6 hours PRN
- Tamsulosin 24 capsule 0.4mg PO daily
- Monitor I/O
- If stone passes, plan for discharge
- Possible Stent placement for intractable pain( NPO after midnight, OR cystoscopy next day(01/18/2024)
- PNA
- IV Ceftriaxone 1g IVPB 1g in 50 mL D5W x 7 days(day 2)
- UTI
- IV Ceftriaxone 1g Q24 hours IVPB 1g in 50 mL D5Wx 7 days(day 2)
- Hydration/Pain Control
- Fever control if needed
- Repeat Urine analysis
- Labs and Vitals
- Repeat Vital signs Q4 hours
- Repeat CBC(monitor anemia) and BMP Q24 hours
