Identifying data:

• Date & Time: 3/31/23
• Full name: ———-
• Address: ——-
• Date of birth: –/–/–
• Location: Flushing, NY
• Source of information: Self
• Reliability: Reliable
• Source of referral: Self

 

Chief complaint: abdominal pain x 4 hours

HPI:

94 y/o M BIB EMS from an assisted living facility with PMHx CAD, BPH, hx nephrolithiasis c/o LLQ abdominal pain that began at 1 am this morning. Pain radiates towards left flank. Patient describes the pain as an intermittent sharp pain, 8/10 in severity. Reports that pain worsens with movement. Patient states he believed it was gas at first and took 2 gas-x, no relief. Patient states he had similar symptoms about 1 year ago where he was hospitalized for a complicated UTI. Admits to dysuria, urinary frequency, incontinence, chills, fever. States he has not noticed blood in his urine. Patient has a urologist but states he has not seen urologist in “a few years”. Patient also complains of productive cough x 1 month with non-bloody thick white mucus. States cough was worse at night while trying to sleep. Reports that the cough has slightly improved recently. Patient reports he was taking mucinex DM for cough and had little relief. Patient states he has followed up with PCP for cough and was prescribed benzonatate, had temporary relief, states he has stopped taking it and cough has persisted. Denies hemoptysis, chest pain, SOB, dizziness, nausea, vomiting, diarrhea, constipation, nocturia, sick contacts, recent travel, sore throat, nasal congestion.

 

Medications:

• Aspirin 81mg chewable tablet QD
• Finasteride 5mg tablet QD
• Rosuvastatin 20mg tablet QD
• Tamsulosin 0.4mg capsule QD
• Acetaminophen 650mg tablet Q6H PRN
• Mucinex DM cough syrup 400mg/20mL Q4H PRN
• Simethicone (Gas-x) 125mg 1-2 tablets PRN
• Denies herbal supplement use.

Medical History:

• Coronary artery disease x 35 years
• Benign prostate hypertrophy x 30 years
• Osteoarthritis x 20 years
• Past hospitalization – 5/22/22 sepsis 2/2 pyelonephritis (coag negative staph treated with doxy/ceftriaxone for 7 days)

Surgical History:

• Coronary artery bypass graft (CABG) – 2001 NYPQ, no complications
• R total knee replacement – 2017 NYPQ, no complications
• L partial knee replacement – 2019 NYPQ, no complications
• Transurethral microwave thermotherapy (TUMT) – 2011 NYPQ, no complications

Allergies:

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

Family History:

• Mother: deceased at age 98 from natural causes, hx HTN, HLD, DM2
• Father: deceased at age 83 from CHF; hx HTN, MI at age 76, HLD
• 2 kids (2 sons): alive and well

Social History:

• Nonsmoker
• Denies alcohol use. Denies illicit drug use
• Occupation: retired
• Caffeine: denies caffeine use
• Marital history: married
• Home situation: living in assisted living facility (Boulevard Home Assisted Living). Patient is independent in all ADLs except bathing.
• Sexual history: not currently sexually active

PCP: Frank Evanov, MD; 516-352-1500

Urologist: Harris Mark Nagler, MD

 

ROS:

• General: Admits to fatigue, fever, chills. Denies 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: Admits to cough. Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations, irregular heartbeat, syncope, known heart murmur.
• Gastrointestinal: Admits to constipation. Denies nausea, vomiting, constipation, intolerance to specific foods, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, hematochezia, melena, hematemesis.
• Genitourinary: See HPI
• Musculoskeletal: Admits to history of arthritis, joint pain. Denies 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: Admits to history of anxiety, currently controlled. Denies depression/sadness, OCD.

 

Physical Exam: 

Vitals:

BP: 166/68 (seated)

HR: 92 beats/min (regular)

RR: 29 breaths/min (labored)

Temp: 39 C (oral)

O2: 89% (room air)

HT: 170.2cm WT: 81.6kg BMI: 28.19 kg/m2

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

Skin: Warm, dry. No rashes. No cyanosis.

HEENT: Head – Atraumatic, normocephalic.

Ears – Symmetrical, no external deformities

Eyes – No conjunctival pallor, no scleral icterus. PERRL. EOMI.

Nose – Nares patent B/L

Throat – No pharyngeal erythema, no exudates.

Chest/lungs: Scattered B/L crackles. No rales, rhonchi or wheezing. No accessory muscle use.

Heart: RRR. No murmurs, gallops.

Abdomen: Symmetrical, no striae, no scars. Soft and nondistended. Normoactive bowel sounds in all 4 quadrants. Diffuse tenderness of lower quadrants. No guarding, no rebound, no palpable masses. No CVA tenderness.

Extremities: No cyanosis, edema or deformities. No tenderness. Equal pulses in upper and lower extremities. FROM.

Male GU: External genitalia unremarkable. Patient is voiding in diaper.

Neuro: Strength and sensation intact. GCS = 15

 

Differential:

• Cystitis/Pyelonephritis
• Nephrolithiasis
• Ruptured renal cyst
• Diverticulitis
• Pneumonia
• Pulmonary embolism
• Viral pathogen – influenza, covid, rsv, etc

 

Workup:

• Labs:

Urinalysis w/ Reflex culture
Urine color	Orange *
Urine appearance	Cloudy *
Urine glucose	Negative
Urine bilirubin	Negative
Urine ketones	Trace *
Urine specific gravity	1.017
Urine blood	Large *
Urine pH	7.5
Urine protein	30 *
Urine urobilinogen	0.2
Urine nitrite	Positive *
Urine leukocyte esterase	Large *
Urine WBC	>100 *
Urine RBC	>100 *
Urine bacteria	Positive *
Urine squamous epithelial cells	0
Urine hyaline casts	1

 

CBC
WBC	6.53
Platelets	161
Hemoglobin	11.5 *
Hematocrit	36.0 *
Neutrophils	92.0 *
Lymphocytes	6.0 *
Esosionophils	0.30

 

BMP
Sodium	137
Potassium	4.8
Chloride	99
Carbon dioxide	24
Blood urea nitrogen	26.8 *
Creatinine	1.24 *
Glucose level	160 *
Anion gap	14
Calcium level total	8.9
Magnesium	2.0
Phos	3.2

 

LFTs
Protein Total	6.7
Albumin Level	4.0
SGOT	22
SGPT	11
Bilirubin total	0.5
Bilirubin direct	0.2
ALK	82

 

PT/INR
APTT	23.4 *
INR	1.14 *

 

GFR
Higher GFR estimate	40 *
Lower GFR estimate	35 *

Lactate – 2.2 *

Procalcitonin – 0.11

Respiratory pathogen PCT panel – negative

Type and screen

• Imaging:
  • CT abdomen and pelvis with IV contrast:
    • Left perinephric stranding with moderate to severe left hydronephrosis with multiple left renal pelvis calculi present measuring 0.8 – 1.6 cm.
    • Multiple large urinary bladder calculi measuring up to 2.4 cm
    • Prostatomegaly (chronic finding)
  • CXR 1 view (AP):
    • Cardiomegaly
    • Small to moderate left pleural effusion with left basilar atelectasis
    • Pneumonia not excluded in left lower lobe
  • CTA Chest with IV contrast
    • No central PE noted
    • Cardiomegaly
    • Trace B/L pleural effusions with bibasilar atelectasis

 

Assessment:

94 y/o M with prior hospitalization 1 year ago for sepsis 2/2 UTI and pneumonia presents from an assisted living facility c/o left abdominal pain and flank pain. Patient was found to have sepsis 2/2 pyelonephritis and acute hypoxic respiratory failure. Vitals remarkable for fever (Tmax 39.7 rectal), hypoxia to 88% (room air) with improvement using 3L NC. Labs reveal positive UA, elevated lactate to 2.2, Cr elevated to 1.24 and no leukocytosis, but a neutrophilic predominance is present. CTAP w/ contrast shows new left moderate to severe hydronephrosis with left renal pelvic calculi measuring 0.8 – 1.6 cm and multiple urinary bladder calculi measuring up to 2.4 cm. CXR reveals small left pleural effusion, pneumonia unable to be ruled out.

Plan:

• Sepsis
  • Activate sepsis code
  • Obtain IV access w/ 2 large bore IVs
    • Fluids LR 125 ml/min
  • Obtain blood cultures x 2 different sites
  • Initiate broad spectrum abx: cover for sepsis 2/2 UTI and possibly pneumonia
    • Meropenem 1g IV q12h and vancomycin 1250mg IV q24h
    • Narrow abx pending culture results
  • Vital signs
    • Q4H on floor
  • Monitor strict I&Os q4H
    • Foley catheter placement
  • Trend lactate
• Hypoxia
  • Begin on O2 via nasal canula 2L
  • Wean O2 as tolerated
  • Incentive spirometer 6 times per hr
  • Obtain TTE for hypoxia and cardiomegaly
• Cystitis / Hydronephrosis
  • Urology consult – ureteral stent for possible obstructing renal calculi
    • Deferred due to stone size
  • IR consult – percutaneous nephrostomy
• BPH

• • Continue finasteride 5mg tablet QD
  • Continue rosuvastatin 20mg tablet QD

• CAD
  • Continue rosuvastatin 20mg tablet QD
  • Continue aspirin 81mg chewable tablet QD

• Pain/fever
  • Tylenol 650mg PRN
• DVT prophylaxis
  • SCDs
• Other
  • Diet: Kosher & cardiac diet after percutaneous nephrostomy
  • Activity: Ambulate up with assistance
  • Disposition: admit to medicine
  • Notify provider if:
    • Temp > 38 or < 36
    • SBP: > 180 or < 90
    • HR > 110 or <60
    • RR > 22 or < 10
    • SpO2 < 90
  • Code: full
    • No advance directives on file
    • No listed health care proxy

 

SOAP note 3/31:

94 y/o M who presented with sepsis, moderate to severe left hydronephrosis and multiple left renal pelvis calculi post op day 1 s/p left percutaneous nephrostomy. At 8am vital signs reveal he is febrile to 38.4, tachy to 123, and well maintained on 3L O2 via nasal cannula. Urine output overnight was 675. On labs this AM, WBC down to 10.24 from 17.94, hematocrit down to 30.9 from 32.6, platelets down to 126 from 159 and lactate was down to 1.7 from 3.2. Pain is well controlled. No BM and has not passed gas. Has not been ambulating. On exam patient is AAO x 3, his abdomen is soft and non-tender to palpation, no CVA tenderness. External genitalia appears normal with catheter in place, draining straw colored urine. Left percutaneous nephrostomy tube is draining fruit punch colored urine. Lung exam significant for B/L crackles. Cardiac exam reveals tachycardia. Plan for today is to continue broad spectrum antibiotics pending cultures, continue to trend labs, monitor vitals and I&Os.