H&P 1

HISTORY:

Identifying data:

Date & Time: August 30, 2022, 8:30am

Full name: Mr. K.Z.

Address: Flushing, NY

Date of birth: July 6, 1963

Location: NYPQ, Flushing, NY

Religion: Atheist

Marital status: Married

Source of information: Self

Reliability: Reliable

Source of referral: PCP

Mode of transport: Son

 

Chief Complaint:

“To be cleared for my surgery”

History of Present Illness:

59 y/o male with PMH of hypercholesterolemia presents to pre-admission testing to be cleared for an extracorporeal shock wave lithotripsy for kidney stone removal from left kidney. Pt c/o hematuria that began 2-3 weeks ago. Has a hx of nephrolithiasis and ESWL lithotripsy in 2018. Pt has currently been on an unknown antibiotic for 1 week. Denies fever, chills, abdominal pain, flank pain, dysuria, urinary urgency, urinary frequency, nausea or vomiting.

Translator ID: 352774

 

Past Medical History:

  • Hypercholesterolemia x 4 years, well controlled on medications
  • Immunizations: up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).
  • Past Hospitalization: None

Past Surgical History:

  • Extracorporeal shock wave lithotripsy – 2018, NYPQ, Flushing, NY. Due to nephrolithiasis, no complications.
  • Denies past injuries or blood transfusions.

Medications:

  • Atorvastatin (Lipitor) 10mg, 1 tab PO daily, for hypercholesterolemia, last dose this morning
  • Denies use of herbal supplements.

Allergies:

  • NKDA, no food or environmental allergies.

Family History:

  • Mother – 83 alive, hx of lung cancer.
  • Father – Deceased at age 70, stroke.
  • Maternal/paternal grandparents – Decreased at unknown age & unknown reasons
  • Son – Age 32, alive and well.

Social History:

  • Habits – Admits to caffeine use, 1 cup of coffee in morning. Nonsmoker, denies alcohol use.
  • Travel – No recent travel.
  • Marital history – Married.
  • Occupational history – Grocery store.
  • Home situation – Lives with wife and son in 2-bedroom apartment.
  • Diet – Admits to balanced diet consisting of protein, grains, vegetables.
  • Sleep patterns – Admits to good sleep patter.
  • Exercise – Admits to daily exercise consisting of walking to and from work (about 30 minutes per day).
  • Safety measures – Admits to seat belt use.

 

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss of gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies headaches, vertigo, head trauma.
  • Eyes: Last eye exam 5 months ago. Unknown visual acuity. Denies glasses use, lacrimation, pruritus, visual disturbances, photophobia.
  • Ears: Denies deafness, pain, discharge, tinnitus, hearing aid use.
  • Nose: Denies discharge, obstruction, epistaxis.
  • Mouth/throat: Last dental exam about 2 months ago. Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis, hemoptysis..
  • Cardiovascular: Denies chest pain, palpitations, hx of HTN, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.
  • Gastrointestinal: Has regular bowel movements daily. Last colonoscopy exam 8 years ago. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Admits to hematuria. Last prostate exam 5 years ago. Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain.
  • Sexual History: Denies impotence, history of STIs, contraception use, abnormal discharge.
  • Musculoskeletal: 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, peripheral edema or color changes.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric:  Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

PHYSICAL:

General: Slender male, neatly groomed, appears his stated age of 59.

Vital Signs:

BP:                  R                                 L

Seated             118/82                         121/84

Supine             120/80                         122/82

R: 16/min, unlabored                          P: 62 beats/min, regular

T: 98.7 degrees F (oral)                      O2 Sat: 99% Room air

Height: 68       Weight: 150 lbs          BMI: 22.8

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

Hair: Short, black hair, average quantity and distribution.

Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities.

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals AU. TM pearly grey and intact with light reflect in good position AU. Auditory acuity intact to whispered voice AU. Weber midline. Rinne reveals AC > BC AU.

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth/Pharynx-

Lips: Pink, moist, no cyanosis or lesions.

Mucosa: Pink, well hydrated. No masses or lesions noted. No leukoplakia.

Palate: Pink, well hydrated. Palate intact with no lesions, masses, scars.

Teeth: Good dentition, no obvious dental caries noted.

Gingivae: Pink, moist. No hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink, well hydrated. No masses, lesions or deviation.

Oropharynx: Well hydrated. No injection, exudates, masses, lesions or foreign bodies. Tonsils grade 2 present with no injection or exudate. Uvula pink, no edema or lesions.

Neck: Trachea midline. No masses, lesions, scars, or pulsations noted. Supple; non-tender to

palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink.
Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/25 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

Cardiac: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma.  Respirations unlabored / no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Abdomen: 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. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions. No axillary nodes palpable.

 

DIFFERENTIAL DIAGNOSIS FOR HEMATURIA:

  • Nephrolithiasis
  • UTI
  • BPH
  • Glomerulonephritis
  • Pyelonephritis
  • Prostatitis
  • Urethritis
  • Urethral injury
  • Kidney disease
  • Bladder carcinoma

 

ASSESSMENT/PLAN:

59 y/o male presenting with 2-3 weeks of hematuria dx with nephrolithiasis needing clearance for extracorporeal shock wave lithotripsy.

Instructions post-op:

  • Patient should drink 8-10 glasses of water daily
  • Patient should strain all urine until f/u appointment
  • Follow up appointment in 4 weeks
  • Patient should contact urologist or visit ED if:
    • Fever greater than 101 F
    • Continuous bleeding & dribbling of urine
    • Excessive blood or clots in urine
    • Unable to urinate for more than 6 hours
    • Any onset of weakness, dizziness or lightheadedness
    • Persistent nausea and/or vomiting
  • Patient should be provided with pain medication and be instructed to transition to OTC acetaminophen when possible
    • Vicodin (Hydrocodone 5mg/APAP 300 mg) PO q4-6hr PRN
  • Patient may be given tamsulosin to help relax urinary system to help with passage of stones
    • Tamsulosin (Flomax) 0.4mg PO QD