- Onset: Began at 5 am today.
- Location: Initially started on the side of his back; pain is now also in the stomach.
- Duration: Intermittent pain that comes in waves.
- Characteristics/Associated Symptoms: Throbbing pain, nausea, urinary frequency, sweating, and pain that occasionally radiates to the groin.
- Aggravating Factors: Sitting in the office.
- Relieving Factors: No relief from any interventions.
- Treatments: Tried Tums and position changes, but they were ineffective.
- Severity: Pain rated at 8/10.
Past Medical History:
- Allergies: NKDA (No known drug allergies).
- Immunizations: Up to date.
- Health Description: Generally good health.
- Conditions: Has hay fever and psoriasis, both well-managed.
- Surgeries: Appendix removed at age 10.
- Hospitalizations: Previous hospitalization at age 8 for a broken leg requiring traction.
- Medications: No current daily medications or herbal supplements.
Family History:
- Mother: Deceased at age 51 due to a brain tumor.
- Father: Deceased at age 53 due to leukemia.
- Siblings: One brother in good health.
Social History:
- Marital Status: Married, has four children.
- Living Situation: Resides with immediate family and in-laws.
- Occupation: Works full-time as a plumber.
- Exercise: Lack of regular exercise due to a busy work schedule.
- Substance Use: Smokes one pack of cigarettes per day. No alcohol or illicit drug use.
- Sleep: Sleeps 5-6 hours per night.
Review of Systems (ROS):
- Neurologic: No recent headaches, denies dizziness.
- Head/Eyes/Ears/Nose/Throat (HEENT): No nasal congestion, discharge, or lymph node enlargement.
- Integumentary: Not reviewed.
- Cardiovascular: Denies palpitations.
- Respiratory: No wheezing or shortness of breath at rest.
- Gastrointestinal: Denies heartburn or indigestion; endorses nausea.
- Genitourinary: Not reviewed.
- Musculoskeletal: Not reviewed.
- Hematologic: Not reviewed.
- Endocrine: Not reviewed.
Objective
Vital Signs:
- Temperature: 98.9°F
- Blood Pressure: 160/96 mmHg
- Pulse: 100 bpm
- Respiratory Rate: 22 breaths per minute
- Oxygen Saturation: 98%
- Height: 5 feet 9 inches
- Weight: 195 pounds
- BMI: 28.8
Physical Examination:
- General: Alert, oriented, and cooperative.
- HEENT:
- Head: Normocephalic, hair thick and well-distributed.
- Eyes: Sclera clear, conjunctiva white.
- Ears: Tympanic membranes gray and intact with light reflex; pinna and tragus non-tender.
- Nose: Nares patent without exudate.
- Throat: Oropharynx moist, no lesions or exudate, tonsils 1+/4 bilaterally.
- Teeth: In good repair, no cavities noted.
- Neck: Supple, no lymphadenopathy, thyroid midline, small, and firm without palpable masses.
Laboratory Results:
- Urinalysis:
- Positive for WBCs, small blood, trace protein.
- pH 7.0, specific gravity 1.030.
- Negative for nitrites, ketones, and glucose.
- CBC:
- WBC: 6,000/mm³
- RBC: 5 million/mm³
- Hemoglobin: 15 g/dL
- Hematocrit: 46%
- MCV: 90 fL
- MCHC: 35 g/dL
Imaging:
- Ultrasound Report:
- 5mm smooth round calculus noted at the junction of the ureter and the bladder.
Assessment
Primary Diagnosis:
- Ureteral Calculus (Kidney Stone): The patient’s symptoms of severe, intermittent, throbbing back and abdominal pain that radiates to the groin, along with the presence of a 5mm calculus on ultrasound, are consistent with a diagnosis of ureteral calculus. The urinalysis findings of blood and WBCs further support this diagnosis.
Differential Diagnoses:
- Pyelonephritis: The presence of WBCs in the urinalysis suggests a possible urinary tract infection, but the lack of fever and systemic symptoms makes pyelonephritis less likely.
- Musculoskeletal Pain: Given the patient’s occupation as a plumber, musculoskeletal pain could be a consideration, but the characteristics and location of the pain are more suggestive of a renal origin.
Plan
Diagnostic Testing:
- Consider a non-contrast CT scan of the abdomen and pelvis to further evaluate the size and location of the kidney stone and assess for any possible complications.
Medications:
- Pain Management: Prescribe NSAIDs such as ibuprofen for pain relief.
- Antiemetic: Prescribe an antiemetic such as ondansetron for nausea.
- Hydration: Encourage increased oral fluid intake to facilitate the passage of the stone.
Patient Education:
- Educate the patient on the importance of hydration and advise him to monitor his urine for any changes or the passage of the stone.
- Discuss potential symptoms that would require urgent follow-up, such as fever, worsening pain, or inability to urinate.
Follow-up:
- Arrange a follow-up appointment in 1-2 weeks or sooner if symptoms worsen, to reassess pain, check for the passage of the stone, and consider further intervention if needed.
Lifestyle Modifications:
- Encourage the patient to quit smoking and discuss the potential benefits of smoking cessation for overall health and kidney stone prevention.
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