IM H&P 2

Chief Complaint:
“Lower abdominal pain and constipation for the last 15 days.”

History of Present Illness:
I.L. is a 65-year-old male with a history of hypertension, diabetes mellitus, benign prostatic hyperplasia , and anxiety, presenting with generalized lower abdominal pain and constipation for 15 days. He reports nausea, decreased appetite, and a 40-pound weight loss over the past two months. The patient also mentions difficulty walking and nearly falling 3-4 times daily, with 3-4 actual falls over the past month. He was recently discharged from rehab on 09/20/24, stating that the rehab was unhelpful, though he was given a walker, which he does not use. He lives alone, with family residing outside the country.

PT states he was seen at LIJ Forest Hills the previous week, where a CT scan of the abdomen and pelvis was performed. He was treated with ceftriaxone for a UTI and received a fleet enema, which did not relieve his constipation. He expresses a desire to “start over,” as he feels the prior ED visit did not help. The patient reports dysuria and hematuria for the last week but denies shortness of breath, cough, back pain, blood in stool, chest pain, vomiting, fever, or chills.

ED:Arrived at ER afrebile and vitals stable. Labs showed elevated lactate to 1.9 but no leukocytosis, Cr elevated 1.9/ Foley place in ER for urinary retention. 

On hospital day 3, the patient reports having a large bowel movement overnight with improvement in his symptoms. However, he continues to experience mild nausea. He also expresses concerns about using rectal medications and indicates a desire to discontinue them, despite being educated on their role in managing his symptoms.

DDX:

  • Malignancy 
  • Benign prostatic hyperplasia with urinary retention(causing constipation) 
  • Untreated Urinary tract infection 

Past Medical History:

  • Medical History:
    • Hypertension
    • Diabetes mellitus
    • Benign prostatic hyperplasia (BPH)
    • Anxiety
  • Medications:
    • Metformin 850 mg BID
    • Lisinopril 10 mg daily
    • Tamsulosin 0.4 mg daily
  • Surgical History: None
  • Allergies: No known drug, food, or environmental allergies

Family History:

  • Mother: Deceased at age 82, 
  • Father: Deceased at age 74, 
  • Siblings: None
  • Children: None reported

Social History:

  • Smoking: 10 pack-year history, currently smoking.
  • Alcohol: Denies use.
  • Illicit Drugs: Denies use.
  • Home Situation: Lives alone; family is outside the country.
  • Occupation: Retired.
  • Exercise: Denies regular exercise.
  • Diet: Reduced appetite in recent months.

Review of Systems:

General: Denies fever, chills, fatigue, night sweats, and unintentional weight loss. Reports recent improvement in abdominal pain after a bowel movement.
Skin, Hair, Nails: Denies rashes, pruritus, discolorations, or changes in hair distribution.
HEENT: Denies headaches, visual disturbances, hearing loss, tinnitus, epistaxis, sore throat, or congestion.
Neck: Denies neck pain, stiffness, or swelling.
Pulmonary: Denies cough, dyspnea, wheezing, or hemoptysis.
Cardiovascular: Denies chest pain, palpitations, or orthopnea.
Gastrointestinal: Reports recent large bowel movement overnight with improvement in abdominal pain but continues to have mild nausea. Denies vomiting, diarrhea, blood in stool, or melena.
Genitourinary: Foley catheter in place.
Musculoskeletal: Reports difficulty ambulating with frequent near falls but denies joint pain, swelling, or muscle pain.
Nervous system: Denies dizziness, weakness, tingling, numbness, or changes in mental status.
Hematologic: Denies easy bruising, bleeding, or history of anemia.
Endocrine: Denies excessive thirst, heat or cold intolerance, or unexplained weight gain.
Psychiatric: Reports anxiety but denies depression, mood swings, or suicidal ideation

Physical Exam:

  • Vitals:
    • Weight: 69.5 kg (153 lb)
    • Height: 70 inches
    • BMI: 21.98 kg/m²
    • BP: 132/78 mmHg
    • HR: 76 bpm
    • RR: 14 breaths per minute
    • Temp: 98.2°F
    • SpO₂: 98% on room air
  • General: Alert, 65-year-old male, appears mildly fatigued but in no acute distress.
  • HEENT: Normocephalic, atraumatic. PERRLA.
  • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses 2+ bilaterally, no JVD.
  • Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
  • Abdominal: Soft, non-tender, non-distended. Bowel sounds normal in all quadrants. No guarding or rebound tenderness.
  • Genitourinary: Mild suprapubic tenderness noted. No palpable bladder distention. Foley catheter in place, no signs of infection at insertion site.
  • Musculoskeletal: Gait unsteady, with noted difficulty ambulating. Strength 5/5 in all extremities, but patients have reported multiple falls recently. No joint swelling or tenderness.
  • Neurological: Alert and oriented x3. 

Labs/Imaging:

Imaging:

  • CT Abdomen and Pelvis without IV contrast:
    • A 1.5 cm indeterminate left renal lesion, possibly representing a hemorrhagic cyst.
    • Circumferential bladder wall thickening, which could be related to a combination of underdistention and sequelae of bladder outlet obstruction from BPH.
  • Chest X-ray: No evidence of acute cardiopulmonary disease.

Assessment/Plan:

65-year-old male admitted with acute kidney injury secondary to dehydration and urinary retention from benign prostatic hyperplasia, presenting with generalized lower abdominal pain and constipation. Imaging revealed a 1.5 cm indeterminate left renal lesion, possibly a hemorrhagic cyst, and circumferential bladder wall thickening likely due to underdistention and bladder outlet obstruction from BPH. The patient’s creatinine pattern improved from 1.94 to 1.6 and then to 1.53. He was started on piperacillin/tazobactam (Zosyn) for urinary tract infection (UTI) after failing to respond to outpatient antibiotics. The patient reports a large bowel movement overnight, with mild nausea persisting. Vitals are stable, with mild suprapubic tenderness noted on exam and a Foley catheter in place without signs of infection. The patient declined NG tube placement for GoLYTELY after education, opting for rectal Dulcolax instead. Continued stabilization and monitoring of renal function and bowel management will be prioritized before considering discharge.

Urinary Tract Infection (UTI):

  • Currently on Zosyn due to lack of response to outpatient antibiotics.
  • Blood cultures are negative to date.
  • Foley catheter in place for benign prostatic hyperplasia (BPH).

Acute Kidney Injury (AKI):

  • Creatinine levels trending from 1.94 to 1.6 to 1.53.
  • Hypercalcemia likely due to dehydration; continue intravenous fluids (IVF).

Constipation: Chronic 

  • Patient had a large bowel movement overnight with improvement in symptoms, though still experiencing mild nausea.
  • Continue Zofran as needed
  • Continue lactulose orally at bedtime.
  • Offer rectal Dulcolax despite patient refusal.

Renal Mass

  • Non Emergent MRI of Abdomen 

Unintentional weight loss

  • Outpatient urology referral for enlarged prostate.
  • Gastrointestinal referral for eventual colonoscopy.

Acute Urinary Retention:

  • Related to BPH with Foley catheter in place.
  • Continue Tamsulosin (Flomax).

Patient Education

You were admitted to the hospital with several health concerns. The main issue is acute kidney injury , which occurred because your kidneys were not getting enough fluids due to dehydration. This dehydration was caused by urinary retention, where your bladder wasn’t emptying properly because of benign prostatic hyperplasia , an enlarged prostate. BPH can cause difficulty urinating, leading to a backup of urine, which stresses the kidneys.

Additionally, you developed a urinary tract infection , which is being treated with antibiotics (Zosyn). The infection likely arose due to the urine retention. You’ve also been experiencing constipation, which can happen when the bladder isn’t functioning well, or due to medications or dehydration. To manage the constipation, you’ve had treatments to encourage bowel movements, and this is improving.

Your imaging also showed two findings: circumferential bladder wall thickening, which is likely related to your bladder not being properly emptied because of the prostate obstruction, and a small renal mass on your left kidney, which might be a hemorrhagic cyst. This mass will need further evaluation, but it doesn’t appear to be an urgent issue right now.

Lastly, the Foley catheter is in place to help empty your bladder and relieve the pressure caused by the BPH, and we are monitoring your kidney function closely to ensure it continues to improve.