Identifying Data:

Full Name: T.M.

Sex: Male

DOB: 09/30/1946

Race/Nationality: Caucasian

Marital Status: Married

Address: New York, NY

Religion: Christian

Date & Time: 9:00AM 11/30/2021

Location: New York Presbyterian Queens Hospital

Source of Information: Self

Reliability: reliable

Source of Referral: Self

Transportation: Driven by wife to ED

Chief Complaint: “I have bad pain in my scrotum and side” x24 hours

History of Present Illness:

75 y/o covid-negative male with PMHx of recurrent nephrolithiasis and Crohn’s Disease presented to the ED 6 hours prior with initial complaints of sharp, shooting intermittent 8/10 pain in the left scrotum and flank that first started yesterday morning. His pain is now described as 2/10 and dull. He believes he passed a kidney stone during urination within the last 1-2 hours. No attributable aggravating/relieving factors or treatments tried. Bedside ultrasound performed in ED shows hydronephrosis consistent with distal nephrolithiasis. Patient denies ever needing a procedural intervention to pass stone. Patient admits to dysuria, pelvic pain, left flank, and left scrotal pain. Patient denies Hx of STIs, fever, N/V/D, penile discharge, changes in urination such as frequency, urgency, or incontinence, perineal pain, or cloudy urine.

Past Medical History:

• Nephrolithiasis, x45 years
• Crohn’s Disease, x57 years
• Benign Prostatic Hypertrophy
• Up-to-date on immunizations
  • Vaccinated against SARS-CoV-2, Moderna 2 doses

Past Surgical History:

• Ileum resection (18 inches) – 1970s
• Cataract Surgery – Right eye, 10/21
• No prior transfusions
• No complications of surgical procedures

Current Medications:

• Finasteride 5mg PO 1x/daily
• Adalimumab (Humira) 40mg SubQ q2wk
• Allopurinol 300mg PO 1x/daily
  • *Pt states he is taking other medications for his Crohn’s disease but is not sure of the names

Allergies:

• NKDA
• No known food or environmental allergies

Family History:

• Mother – Deceased of “old age”, denies medical conditions
• Father – Deceased of “old age”, denies medical conditions
• Maternal Grandmother – unknown
• Maternal Grandfather – unknown
• Paternal Grandmother – unknown
• Paternal Grandfather – unknown
• Siblings – none
• Children – none

Social History:

• Habits – alcohol (occasional use, 1 drink/month), denies ever using tobacco, denies ever using marijuana or other illicit drugs, caffeine (rarely consumes)
• Travel – no recent travel
• Occupation – Retired from office job
• Marital History – Married. No pets
• Diet – Denies following a special diet. Reports eating 3 meals per day consisting of American diet and water.
• Reports feeling rested and sleeping well throughout the night. Sleeps 7-8 hours per night.
• Exercise – Not exercising regularly but states he walks a lot while running errands.
• Safety measures – wearing seatbelt. Does not engage in sports that require helmet use
• Sexual History – Sexually active with monogamous partner (wife). Denies impotence/anorgasmia, no history of STDs. Not using condoms.

Review of Systems:

• General
  • Denies weight loss, loss of appetite, generalized weakness/fatigue, fever/chills/night sweats
• Skin, hair, nails
  • Denies excessive sweating, pigmentations, moles, change in hair distribution, rash, pruritis
• Head
  • Denies headache, vertigo, head trauma
• Eyes
  • Denies visual disturbances, abnormal lacrimation, photophobia, or pruritis
  • Last eye exam 2 months prior (Recent improvement in vision after cataract surgery). Visual acuity unknown. Wears glasses for reading.
• Ears
  • Denies deafness, pain, discharge, tinnitus, hearing aids, or feeling of fullness
• Nose/Sinuses
  • Denies epistaxis, congestion, or discharge

• Mouth and Throat
  • Denies bleeding gums, sore tongue/throat, mouth ulcers, voice changes, or dentures. Last dental exam 12 months prior, unremarkable per pt
• Neck
  • Denies swelling/lumps, stiffness, or decreased ROM
• Breast
  • Denies lumps, nipple discharge, or pain.
• Pulmonary System
  • Denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND
• Cardiovascular System
  • Denies chest pain, known murmur, HTN, palpitations, irregular heartbeat, edema/swelling of ankles/feet, or syncope
• Gastrointestinal System
  • Denies changes in appetite, intolerance to specific foods, N/V/D, constipation, dysphagia, pyrosis, flatulence, abdominal pain, jaundice, changes in bowel habits, hemorrhoids, rectal bleeding/blood in stool. Denies ever having stool guaiac/colonoscopy/sigmoidoscopy
• Genitourinary System
  • Admits to dysuria, left scrotal pain, left flank pain
  • Denies changes in frequency, nocturia, urgency, oliguria, polyuria, abnormal color of urine, incontinence
  • Sexual History – refer to Social Hx
  • Last prostate exam/PSA 1 year prior
  • Denies hesitancy/dribbling
• Nervous System
  • Denies sensory disturbances, changes in cognition/mental status/memory, seizures, headache, loss of consciousness, ataxia, loss of strength, or weakness
• Musculoskeletal System
  • Denies muscle/joint pain, deformity, swelling, redness, or Hx of arthritis
• Peripheral Vascular System
  • Denies intermittent claudication, coldness/trophic changes, varicose veins, peripheral edema, or color change
• Hematologic System
  • Denies anemia, easy bruising/bleeding, lymph node enlargement, or history of DVT/PE
• Endocrine System
  • Denies polyuria/polydipsia/polyphagia, heat/cold intolerance, goiter, excessive sweating, or hirsutism
• Psychiatric
  • Denies depression/sadness, anxiety, or obsessive/compulsive disorder. Never seen a mental health professional. Never taken psychiatric medications

PHYSICAL EXAM

Vital Signs:

BP: 165/88 mmHg – sitting & supine, L arm

RR: 14 breaths/min, unlabored

Pulse: 68 bpm, regular

T: 36.4 C (oral)

O2 SAT: 96% on room air

            Height: 67 inches        Weight: 160 lbs           BMI: 25.1

General Appearance: alert & oriented x3, no acute distress. appropriate development and body habitus, well nourished, appropriate posture, appears stated age, well groomed

Head: normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU. No strabismus/exophthalmos/ptosis. Sclera white, cornea clear, conjunctiva pink. No erythema of lacrimal sack. Visual acuity 20/20 OU. Visual fields full OU. PERRLA. EOM intact with no nystagmus. Red reflex intact OU. Retinal vessels unremarkable (no AV nicking, hemorrhages, exudates, or neovascularization). Optic disc unremarkable (cup-to-disc ratio < 0.5 OU with appropriate color & contour), no papilledema. Macula & fovea unremarkable, no macular degeneration

Ear: Appropriate in size. Ear and tragus nontender AU. No lesions/masses/trauma visualized on external ear. No discharge/foreign bodies in external auditory canals AU. TM pearly white/intact with cone of light in appropriate position AU. No cerumen bilaterally. Auditory acuity intact to whisper voice AU. Weber midline / Rinne AC>BC AU.

Nose: Symmetrical, no masses/lesions/deformities/trauma/discharge. No tenderness/bogginess/step off to palpation. Nares patent bilaterally. Nasal mucosa pink and moist. Septum midline. Inferior nasal turbinate appropriate size on anterior rhinoscopy. No ulcerations/foreign bodies visualized.

Sinuses: No tenderness to palpation over bilateral maxillary/frontal sinuses.

Mouth & Throat:

Lips: Pink & moist. No cyanosis, lesions, or ulcerations

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

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

Teeth: No dental caries, missing, or loose teeth. All teeth have appropriate shape.

Gingivae: No hypertrophy or recession. Unremarkable

Tongue: pink, well papillated. Frenulum intact. No masses/lesions/deviation.

Oropharynx: Well hydrated, no exudate/masses/lesions/erythema/postnasal drip/foreign bodies noted. Grade 1 tonsils. Uvula pink, midline with no lesions or edema.

Neck: Trachea midline. No masses/lesions/pulsations noted. Neck supple, non-tender to palpation. Free range of motion. No stridor noted. No cervical adenopathy. No carotid pulses/thrills/bruits heard on auscultation. Thyroid is non-palpable, unremarkable. No goiter

Lymph nodes: Non-palpable, unremarkable preauricular, postauricular, submandibular, posterior cervical chain, anterior cervical chain, supraclavicular, and infraclavicular lymph nodes

Cardiovascular: JVP is 2.5cm above sternal angle with head of bed at 30 degrees. PMI located at the 5^th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. RRR. S1/S2 distinct with no murmurs or S3/S4 heard. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical with no deformities or trauma. No tenderness on palpation. Respirations unlabored, no paradoxical respirations or use of accessory muscles. Lat/AP diameter 2:1.

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

Abdomen: Abdomen symmetric and flat. No scars, striae, or pulsations noted. Bowel sounds are normoactive in all 4 quadrants. No aortic/renal/iliac/femoral bruits heard. Non-tender to palpation and tympanic throughout. No guarding or rebound tenderness. No hepatosplenomegaly to palpation. No CVA tenderness appreciated.

Skin: Midline vertical scar on the abdomen approximately 5mm diameter spanning from the distal abdomen to just below the xyphoid process. Warm and moist with patches of xerosis. Good turgor. Non-icteric. No tattoos noted. No moles.

Hair: Average quantity and distribution. No seborrhea/lice/dandruff noted

Nails: Capillary refill <2 seconds in bilateral upper and left lower extremities. Appropriate color, shape, and thickness.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation.  Full active range of motion with no crepitus in all upper and lower extremities bilaterally.  Full spinal range of motion with no deformities.

Peripheral Vascular: 2+ pulses throughout. No ulcerations. Upper and lower extremities have normal skin color and warm to touch bilaterally. No calf tenderness bilaterally, equal in circumference. No palpable cords bilaterally. No palpable inguinal or epitrochlear adenopathy.

Neurological: Cranial nerves intact. Gait and coordination intact. Sensations intact. 2+ reflexes throughout.

Psychiatric: Appropriate appearance, speech/language, mood, thought process/content, insight/judgement, memory & attention

Genitalia:

Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally, smooth, no masses. Epididymis non-tender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate

No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus. Brown stool.

Assessment:

75 y/o covid-negative male with PMHx of recurrent Nephrolithiasis and Crohn’s Disease presents to the ED with complaints of 8/10 sharp, shooting left flank & scrotal pain x24 hours that has now diminished to a 2/10 dull pain after last urination.

Plan:

• Nephrolithiasis
  • Bedside U/S of kidneys and bladder (completed)
  • Labs: UA, CBC, CMP
  • Treatment: IV maintenance fluids (0.9NS), Ketolorac 30mg IM
  • Discharge upon complete passage of stone
• Crohn’s
  • Continue scheduled follow up with patient’s established GI specialist

Differential Diagnosis:

1. Nephrolithiasis
2. Pyelonephritis
3. Prostatitis
4. Epididymitis
5. Intestinal Obstruction (Crohn’s exacerbation)