Identifying Data :

Full Name: Mr. VR

Address: Flushing, NY
Date of Birth: February 17 , 1984

Age: 37 yo
Date & Time: November 9, 2021 9:20 am
Location: NYPQ, Flushing, NY
Religion: None
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Physician

Chief Complaint : “Blocked nephrostomy and burning.” X5 days

History of Present Illness :
37 year old male patient with a past medical history of cholelithiasis and ureteral stent presents to the ED for a clogged nephrostomy. Patient states nephrostomy became blocked on the evening of 11/5/21 but did not want to come to the ED over the weekend. He also experiences burning in his right lower flank rated a 8/10 with no radiation. He took Percocet for the pain but does not remember how much. Patient also states the nursing home gave him antibiotics for a urinary tract infection. Patient denies itching or burning at the site of nephrostomy opening. He has experienced this several times before, up to 1-2 times a year in the 5 years he has had a nephrostomy. Patient denies fever, nausea, vomiting, diarrhea, constipation, shortness of breath, or chest pain. Denies recent travels, dizziness, and loss of consciousness.

Past Medical History

• Cholelithiasis – 2014

• Immunizations – Up to date; flu vaccine yearly

Past Surgical History

• Uretral Stent – 2014
• Nephrostomy – 2016

Medications

Currently On :

• Percocet 10 mg PO PRN

Allergies

• Denies food allergies
• Allergy to Polymxcin 

Family History

• Mother – Aged 60 yo, alive, hypertension
• Father – Aged 62, alive, no significant medical history

• Sister – Aged 40, alive, no significant medical history
• No Children, Never married

• Denies family medical history of cancer or respiratory complications

Social History

Mr. VR is a 37 year old male who lives in a nursing home. Patient is unemployed and lives a sedentary lifestyle. He has not seen his family in several years. Patient is not currently in a relationship and does not have any pets. 

Habits : Patient used to drink heavily around 3 – 4x a week with 2-3 standard drinks each time. He has cut down drinking to special occasions in the past two years. Patient has tried to stop smoking cigarettes for the past 5 years. He smokes 1 – 2 cigarettes a day and smokes marijuana daily.

Travel : Denies recent travel. 

Diet : Patient eats a bland a balanced diet served at the nursing home. Meals typically consist of rice, chicken, and steamed vegetables. 

Exercise : Patient maintains a predominantly sedentary lifestyle due to nephrostomy tubing.  

Sexual History : Heterosexual, never married and no current partners. States he has not been sexually active in the last 5 years. Denies history of sexually transmitted diseases.

Review of Systems

General – Patient appears weak, tired, and with poor pallor. Patient is mentally alert while laying down. Patient experiences weakness. Denies loss of appetite, fever, chills, night sweats. 

Skin, hair, nails – Denies excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures. 

Eyes –  Denise dry eyes visual disturbances, lacrimation, photophobia, pruritus, or use of reading glasses. Last eye exam was 1 year ago.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, use of dentures. Last dental exam was over 2 years ago – normal. 

Neck – Denies neck stiffness, decreased range of motion, localized swelling, or lumps.

Breast – Denies lumps, pain, or discharge.

Pulmonary system – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular system – Denies hypertension, edema in calves, ankles, chest pain, palpitations, or syncope.

Gastrointestinal system – Denies nausea, vomiting, constipation or diarrhea. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.  

Genitourinary system – Patient experiences right flank pain for the past 5 days. Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, or awakening at night to urinate.

Menstrual and Obstetrical — N/A

Nervous – Denies seizures, headache, loss of consciousness, or change in mental status / memory. 

Musculoskeletal System – Patient experiences weakness. Denies aching, swelling, or redness. Denies coldness or tingling in extremities. 

Peripheral Vascular System – Denies coldness, edema, weakness, or tingling in extremities. Denies trophic or color changes.

Hematological System – Denies anemia, echymosis, lymph node enlargement, history of DVT/PE, or drug infusions.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating or goiter.

Psychiatric – Denies depression, anxiety, OCD, or ever seeing a mental health professional. Not suicidal or homicidal.

Vitals

Blood Pressure 

(R) 132/80 (L) 125/80 seated

(R) 132/80 (L) 125/80 supine

Pulse Rate – 70 bpm, regular

Respiratory Rate – 16/min, unlabored

Temp – 98.2 °F (axillary)

O2 Sat – 99% room air

Height – 5’5

Weight – 135 lbs

BMI – 22.5

Physical Exam

General: Male patient appears weak, with poor pallor, and good-hygiene while seated. He is alert and looks tired. Patient does not appear to be in respiratory or cardiac distress.

Skin: Poor pallor. Warm and moist with good turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koiconychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, greasy, average texture, and good luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU. 

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

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

Palate: Pink, well hydrated. No lesions, masses, scars.  

Teeth: Teeth intact, no dentures. White and no cavities. 

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

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

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted.  Supple, non-tender to palpation.   Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits symmetric throughout. No adventitious sounds.

Cardiovascular: History of hypertension for 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.

Abdominal: Two nephrostomy openings present in the RLQ and suprapubic region.Abdomen is round with no striae or pulsations. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation.  Bowel sounds normoactive in all four quadrants. No CVA tenderness.

Genital : Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Rectal : No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown and Hemoccult negative

Neurologic: 

Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. He recalls 3/3 objects at 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue. 

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskelteal : No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper and lower extremities bilaterally.  Full spinal range of motion with no deformities.

Assessment & Plan

37 year old male with past medical history of cholelithiasis and ureteral stents presents with blocked catheter and lower right flank pain. His examination is notable for rounded abdomen and tenderness to palpation on the lower right flank. 

Problem List :

• Blocked Nephrostomy 

D/Dx : 

• Cholelithiasis – Patient has a history of cholelithiasis that resulted in the placement of a urinary stent and nephrostomy. As patient currently presents with lower flank pain and obstruction of nephrostomy, the likelihood of cholelithiasis is high.

• Pyelonephritis – Infection of the kidney is highly likely has patient delayed admission to the ED for blocked nephrostomy and presents with severe pain.

• Urinary Tract Infection– Infection of the urinary tract is highly likely as the patient had a urinary stent for 2 years, nephrostomy for 5 years, and frequent nephrostomy obstructions.

• Hydronephrosis – Patient delayed admission to ED for nephrostomy obstruction. Patient also presents with severe pain in right flank. Hydronephrosis is highly likely. 

• Cancer – Patient presents with blocked nephrostomy. Cancer should be considered as a possible source of obstruction. 

Plan : 

• Abdominal Ultrasound – evaluate for cholelithiasis 
• Urine Culture – evaluate for UTI and causative agent
• Ceftriaxone 1 g IV once daily or Piperacillin-Tazobactam 3.375 g IV x 6 hrs → for acute UTI without presence of multidrug-resistant gram-negative organism
• Piperacillin-Tazobactam 3.375 g IV x 6 hrs or Antipseudonomal Carbapenem 500 mg IV x 6 hours or Meropenem 1g IV x 8 hours → for acute UTI with presence of multidrug-resistant gram-negative organisms

• Discuss nephrostomy hygiene and care to patient
• Contact family or nursing home to arrange appointment with nephrologist 
• Follow-up in 48 – 72 hours after discharge

• Medication Review : Patient states using opioids for pain management but does not have any medical conditions that suggests need for continual use. 

Plan :

• Review patient’s use and necessity of opioids
• Contact family or nursing hoe to arrange appointment with a primary care physician 

• General Lifestyle Management : Patient presents with concerning lifestyle factors such as smoking, drinking, and no physical activity that may exacerbate renal complications. 

Plan : 

• Instruct patient to eat a balanced diet with fruits, vegetables, whole carbs, and protein
• Encourage patient to engage in light physical activity
• Educate patient on the risks of cigarette and alcohol use on renal function