Patrick Brown 42 year old male

S.
CC: nausea, stomach and back pain
HPI
O: 5am
L: back and stomach, with the pain sometimes shooting down his groin.
D: intermittent
C: throbbing, rates pain 8/10.
A: sitting seems to make it worse
R: not discussed
T: not discussed
PMH: Describes his health as good. Has hayfever and psoriasis.
Current medications: No current medications
Allergies: NKDA
Prior illnesses/injuries: No previous illnesses. Broken leg at age 8.
Operations and hospitalizations: Hospitalized at age 8 for a broken leg that required traction.
Immunizations: UTD
Family Hx: Mother died at age 51 from a brain tumor. Father died at age 53 from leukemia. Has
one brother that is in good health.
Social Hx: Married, has 4 children. Works full time as a plumber. Smokes 1 pack of cigarettes a
day. Denies alcohol or illicit drug use.
ROS
Constitutional: Thinks he might have a fever because he has been sweating. Rates pain 8/10.
GI: nausea and stomach/back pain that he describes as throbbing
GU: Reports going to the bathroom more often.
O.
Physical Exam
VS: T- 98.9 BP 160/96 P 100 R 22 Oxygen saturation 98%
Constitutional: uncomfortable appearing male. Alert, oriented and cooperative.
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear,
conjunctiva white. Tympanic membranes gray and intact with light reflux noted. Pinna and
tragus non-tender. Nares patent without exudate. Oropharynx moist, no lesions or exudate.
Tonsils bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy.
Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 noted, no murmurs noted.
Respiratory: Lungs clear to auscultation bilaterally. Respirations unlabored.
GI: Abdomen slightly distended, with decreased bowel sounds noted. Guarding on palpitation.
Positive CVAT on right side. No organomegaly noted.
Urinalysis: Positive WBCs, small blood, trace protein, pH 7.0 Sp Gr 1.030, neg ketones, neg
glucose
CBC: WBC 6000mm3 RBC 5 million Hgb 15g Hct 46% MCV 90 fL MCHC 35 g/dL
Ultrasound showed a 5mm smooth round calculus at junction of the ureter and the bladder.
Assessment
1. Ureterolithiasis (ICD 9 code 592.1) The pain that Patrick is feeling is called renal colic.
Renal colic is caused by obstruction of the flow of urine. The pressure builds up behind
the stone causing painful swelling of sensitive structures. The pain can radiate along the
path of the urinary tract which begins at the high back over the kidney and travels down
to the lower abdomen, groin, and into the genitals. Because the pain is so severe, patients
will often experience nausea and vomiting. Because Patrick is restless and unable to find
a comfortable spot, it helps to distinguish pain from a stone vs pain from an intestinal
problem. Patients with an intestinal problem such as appendicitis or diverticulitis want to
lie still (Kidney stones, 2012). Patricks symptoms, UA, and US results all correlate with
ureterolithiasis.
Plan
1. Medications: Norco 5/325mg Sig: Take 1 tablet every 4 to 6 hours as needed for pain.
Quantity #30 (thirty). NO refills (Norco, 2013).
2. No additional diagnostic tests are needed.
3. Pt should be educated on straining his urine every time he urinates to monitor for the
passing of the stone. If his stone passes, he could bring it in and it could be analyzed to
identify what type of stone it is. This could be beneficial if he continues to develop stones in
the future (Gul & Monga, 2014). With his stone being 5mm, there is a chance that it may
still not pass on its own. If after 2 weeks it has not passed, we will re-evaluate what to do
next. Since Patrick is going to be prescribed a narcotic, he will need to understand the risks.
Norco can make him sleepy and he should not drive or operate machinery while taking it.
Norco can also upset his stomach so he should take with a meal or small snack. Patients
presenting with nephrolithiasis for the first time have a 50% chance of recurrence by 10
years. He should increase his fluid intake to maintain a urine output of at least 2 to 2.5 liters
 per day. This could help to cut the risk of stone recurrence in half (Richmann, Obell &
Pareek, 2014)
4. No referral needed at this time. If after 2 weeks his stone has not passed, I would refer him
to a urologist.
5. Patrick will need to return in 2 weeks. I would do a repeat US to ensure that the stone has
passed. If his symptoms worsen or change he will need to call and come back sooner for
evaluation.
 References
Gul, Z., & Monga, M. (2014). Medical and Dietary Therapy for Kidney Stone Prevention.
Korean Journal Of Urology, 55(12), 775-779. doi:10.4111/kju.2014.55.12.775

Kidney stones: common, painful, preventable. (2012). Harvard Men's Health Watch, 16(6), 1-5.

Norco. (2013). In Epocrates Essentials for Android [Mobile application software]. Retrieved
from http://www.epocrates.com/mobile/android/essentials

Richmann, K., O'bell, J., & Pareek, G. (2014). The Growing Prevalence of Kidney Stones and
Opportunities for prevention. Rhode Island Medical Journal,97(12), 31-34.