H&P #2

Identifying data:

  • Date & Time: 3/29/23
  • Full name: ———-
  • Address: ——-
  • Date of birth: –/–/–
  • Location: Flushing, NY
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: “Stomach and side pain” x 3 days

Original HPI: J.C. is a 74 year old female with PMHx HTN, HLD, currently on dual antiplatelet therapy c/o abdominal pain and hematuria x 3 days. Abdominal pain is primary in LLQ, describes pain as achy and 10/10 in severity. Patient states pain worsens with movement and radiates towards back to the left flank. Patient reports the pain has been worsening over the past 3 days and is associated with nausea and vomiting. Reports multiple episodes of non-bloody, non-bilious, clear liquid emesis daily over 3 days. Admits to dysuria and hematuria. Patient states she has noticed blood clots in urine about the size of a quarter which prompted her to present to ED. Denies recent procedures. History positive for recent trauma, patient states she had a fall about 1 month ago in her home where she slipped on a rug and landed on her back. Patient states she did not notice bruising after injury and did not seek medical treatment. OTC use with Tylenol 1000mg PRN, mild relief. Denies fever, chills, urinary urgency/frequency/retention, incontinence, chest pain, SOB, constipation

ED course: Patient received 1L NS bolus and one dose of Toradol 15mg. Her pain and nausea substantially improved. Afebrile and vital signs stable. Labs are notable for H&H 11.7/35, creatinine 1.5, wbc 14, lactate 2.5, UA 10 WBC/ > 100 RBC / trace leukocyte esterase / 100 protein / large amount of blood.

 

Differential Diagnosis:

  1. Pyelonephritis
  2. Nephrolithiasis
  3. Renal hematoma
  4. Ruptured renal cyst
  5. Renal abscess

 

Medications:

  • levothyroxine – 75mg PO QD
  • rosuvastatin – 10mg PO QD nightly
  • lisinopril-hydrochlorothiazide – 20mg-12.5mg PO QD
  • metoprolol succinate ER 24hr – 50mg PO QD
  • clopidogrel 75 mg PO QD (last dose 3/25)
  • aspirin 81 mg PO QD (last dose 3/25)
  • Tylenol 1000mg PRN
  • Denies herbal supplement use.

Medical History:

  • Hypertension x 30 years
  • Hyperlipidemia x 20 years
  • Hypothyroidism x 30 years
  • Transient ischemic attack (2013)

Surgical History:

  • Reduction of left radial fracture (NYPQ) 2014; no complications

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: deceased at age 84 from natural causes; hx arthritis
  • Father: deceased at age 81 from MI; hx HTN, HLD
  • 2 sons: no significant medical history

Social History:

  • Former smoker ½ pack per day for 50 years; quit 2/05/23
  • Denies alcohol use. Denies illicit drug use
  • Occupation: retired; former transit conductor
  • Caffeine: denies caffeine use
  • Marital history: married
  • Home situation: lives at home with husband
  • Independent in ADLs
  • Sexual history: sexually active, no contraceptive use, no known history of STDs

PCP: Alberto Rozo, DO; 718-457-7000

 

ROS: All pertinent positives and negatives are listing in the history of present illness. All other systems are negative.

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss/gain, loss of appetite.
  • Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies visual disturbances, 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: Admits to history of HTN. Denies chest pain, edema/swelling of ankles or feet, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Admits to nausea and vomiting. Denies abdominal pain, constipation, intolerance to specific foods, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, hematochezia, melena, hematemesis.
  • Genitourinary: See HPI
  • 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, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD.

 

Physical Exam:

Vitals:

T: 36.9 – 37.2 C (oral)

Pulse: 70 – 71 bpm (regular)

RR: 18 breaths/min (unlabored)

BP: 118-120/86-89 (seated)

SPO2: 96-97% (room air)

H: 158 cm W: 64.9 kg BMI: 26.00 kg/m2

General: Alert and orientated x 3. Appears in no acute distress. Well groomed, appears stated age.

HEENT: Head atraumatic and normocephalic. No conjunctival pallor, no scleral icterus. PERRLA, EOMI. External ears symmetrical, no deformities. Nares patent B/L. Pharynx non-erythematous.

Heart: Regular rate, regular rhythm. S1 & S2 distinct with no murmurs. No rubs, no gallops.

Chest/Lungs: Symmetrical, no deformities. Respirations unlabored with no accessory muscle use. Clear to auscultation bilaterally. No rales, rhonchi, wheezing.

Abdomen: No scars, no striae, no ecchymosis. Bowel movements normoactive in all 4 quadrants. Abdomen soft and nondistended. +LLQ tenderness. +Mild left CVA tenderness. No guarding, no rebound, no palpable masses.

Extremities: No cyanosis, no edema. Warm; FROM of all upper/lower extremities bilaterally; no calf tenderness.

Female GU: External genitalia unremarkable. Voiding freely, no foley in place.

Neuro: Strength and sensation intact. GCS = 15

 

Workup:

  • Labs:
Urinalysis w/ Reflex culture
Urine color Red *
Urine appearance Cloudy *
Urine glucose Negative
Urine bilirubin Negative
Urine ketones Negative
Urine specific gravity 1.030
Urine blood Large *
Urine pH 6.0
Urine protein 100 *
Urine urobilinogen 0.2
Urine nitrite Negative
Urine leukocyte esterase Trace *
Urine WBC 10 *
Urine RBC >100 *
Urine bacteria Negative
Urine squamous epithelial cells 2
Urine hyaline casts 0

 

CBC 3/25

19:49

 3/26 10:27 3/26 18:31 3/27 06:31 3/27 17:58 3/28 06:40
WBC 13.93 * 13.63 13.06 12.63 13.89 14.93
RBC 4.08 * 3.48 3.38 3.22 3.03 3.21
Hemoglobin 11.7 9.9 9.7 9.3 8.6 9.3
Hematocrit 35.0 29.9 29.8 28.4 26.4 27.9
Mean Cell Volume 85.8
Mean Cell Hemoglobin 28.7
Mean Cell Hemoglobin Concentration 33.4
Red Cell Distribution Width 14.0
Platelet 218
Mean Platelet Volume 11.2 *

 

BMP 3/25

19:49

 3/26 10:11 3/26 18:31 3/27 06:31 3/28 06:40
Sodium 133 * 130 133 130 130
Potassium 4.2 3.9 4.0 3.7 3.6
Chloride 94 * 94 95 96 96
Carbon dioxide 22 24 23 24 25
Blood urea nitrogen 21.9 31.8 29.4 26.8 18.8
Creatinine 1.48 * 1.47 1.28 1.12 0.95
Glucose level 145 * 113 130 98 121
Anion gap 17 12 15 10 9
Calcium level total 8.9 8.5 8.4 8.2 8.0
BUN/Creatinine ratio 15 22 23 24 20

 

LFTs
Protein Total 6.3 *
Albumin Level 3.6
Globulin 2.7
Bilirubin total 0.7
Bilirubin direct 0.2
Bilirubin indirect 0.5
Aspartate Aminotransferase 82 *
Alanine Aminotransferase 52 *
Alkaline phosphatase 73

 

PT/INR
Prothrombin time 13.6 *
INR 1.17 *

 

GFR
Higher GFR estimate 40 *
Lower GFR estimate 35 *

 

Lactate – 2.5 *

Lipase – 16

aPTT – 32.4

Troponin T – < 0.010

Type and screen

  • Imaging: CT abdomen and pelvis with IV contrast
    • Large left sided perirenal hematoma measuring approximately 10.8 x 3.5 x 7.7 cm. Hyperdensity within the proximal left renal collecting system which may represent blood products. Large amount of perinephric stranding on the left. Multiple bilateral renal cysts are seen.

 

Assessment: 74 y/o F on DAPT with multiple renal cysts found to have a spontaneous large left perirenal hematoma on CT. Available records of prior scan in 2014 revealed minimally complex Bosniak II cyst in the region of current left perinephric hematoma. Patient is hemodynamically stable. On exam there is LLQ tenderness and mild left CVA tenderness. Labs reveal initial H&H 11.7/35, WBC elevated to 14, elevated creatinine at 1.48 (no baseline), lactate 2.5 and UA significant for large blood, trace leukocyste esterase and 100 protein. Needs admission for serial H&H monitoring and antiplatelet management.

Disposition: admit to medical floor

Plan:

  • Perirenal hematoma
    • IV fluids – Dextrose 5% and sodium chloride 0.9% infusion continuous 100mL/hr
    • Trend CBC & BMP– monitor H&H, Cr Q12H (AM & PM labs)
    • Monitor strict I&Os – Q4H
    • Vitals – monitor vitals Q6H
  • Hematuria
    • Consult urology
  • Pain
    • Acetaminophen 975 mg tab PO Q8H
    • Oxycodone immediate release 5mg tablet Q4H PRN (patient may request for severe pain 7-10)
    • Avoid NSAIDs
  • DVT prophylaxis
    • Sequential compression device (SCDs)
  • Anticoagulation
    • Hold aspirin 81 mg PO QD (last dose 3/25)
    • Hold clopidogrel 75 mg PO QD (last dose 3/25)
  • Hypertension
    • Continue lisinopril-hydrochlorothiazide – 20mg-12.5mg PO QD
    • Continue metoprolol succinate ER 24hr – 50mg PO QD
  • Hyperlipidemia
    • Continue rosuvastatin – 10mg PO QD nightly
  • Hypothyroidism
    • Continue levothyroxine – 75mg PO QD
  • Other
    • Diet – regular diet
    • Activity – strict bed rest
    • Call MD if:
      • Temp>101
      • HR > 100
      • SBP> 160 or <100 or DBP>100 or < 60
      • RR> 30 or < 10
    • Code – full
      • No advance directives
      • No healthcare proxy

 

3/29 SOAP: J.C. is a 74 year old female who presented on 3/25 with LLQ abdominal pain and left flank pain x 3 days found to have a large left sided perirenal hematoma. Patient continues on strict bed rest. Pain is well controlled. Patient is voiding freely, endorses significant improvement in hematuria. Denies nausea or vomiting. On exam there is mild tenderness to left flank, no ecchymosis present. Temperature is significant to 38.1 at 4pm, vital signs otherwise stable. H&H currently stable to 9.3/27.9. Will continue to monitor H&H and hold ASA and Plavix.