burning on urination
SUBJECTIVE DATA (S)
Source of History: Patient is the source of the history; appears reliable.
History of present illness (HPI)
Patient a 47-year-old Asian male, presents to the medical office complaining of lower mid abdominal pain and blood in the urine for 2 days. He stated that 4 days ago the pain started in the left flank and 2 days later it shifted to the lower mid abdomen. He described the pain as intermittent, sharp, and stabbing which lasts approximately about 10 minutes. He rated the pain as 8/10 on a scale of 0 to 10. The pain is aggravated by moving and repositioning; Took Motrin 400mg PO Q6h PRN, bought over the counter without relief. Denies frequency of micturition, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of urinary stream, hesitancy, dribbling, incontinence, urinary infections, stone; hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted infections. Heterosexual, single, in a satisfying monogamous relationship with girlfriend of 4 years. Denies trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching or passing of gas, constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 daily soft brown stool.
Childhood Illnesses: Denies chickenpox, measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.
Adult Illnesses: Hypertriglyceridemia at age 46 (Patient is currently trying diet, exercise, and fish oil to lower triglycerides).
Psychiatric illnesses: Denies past or present psychiatric illnesses.
Operations: Denies history of operations.
Hospitalizations: Denies Past hospitalizations.
– Multivitamin 1 tablet PO daily.
– Omega-3 fish oil 1 capsule PO daily.
– No known drug or food allergies.
– Allergic to dogs and cats (Reaction: itchy eyes and runny nose).
Tobacco: Denies past or present tobacco use.
Alcohol: Drinks 3-5 12 oz. cans of beer weekly.
Drugs: Denies past or present illicit drug use.
Sexual history: Heterosexual. Monogamous relationship with his girlfriend. He stated that he uses condoms.
Marital status: Single. Good and satisfying relationship with his girlfriend for 4 years; no children by history.
Living situation: Lives by himself in a studio apartment.
Work: Electronic store manager.
Education: Bachelor’s degree- electrical engineer.
– PPD: Negative (05/2016).
– Chest x-ray: Unremarkable (05/2016).
– PSA: 2.4 ng/mg-within normal range (05/2016).
– Hemoglobin A1c: 5.0 -within normal range (05/2016).
– Lipid panel: Within normal limits except triglycerides 170 mg/dl).
– Endoscopy: Unremarkable (2012)
– Colonoscopy: Unremarkable (2012).
– Dental exam: Within normal limits- no cavities or decay (09/2016).
– Eye exam: Vision 20/20 both eyes (07/2015).both eyes)
Maternal grandmother: Medical history unknown. Deceased (age unknown).
Maternal grandfather: Medical history unknown. Deceased (age unknown).
Paternal grandmother: Medical history unknown. Deceased (age unknown).
Paternal grandfather: Medical history unknown. Deceased (age unknown).
Mother: Osteoporosis. Age 76. Living.
Father: Hypertension and hyperlipidemia. Age 80. Living.
Review of Systems
Eyes: Patient stated that he has good vision and has never worn glasses or contact lens. Last eye exam more than 2 years, 20/20 vision. Denies eye pain, redness, discharge, recent changes in vision, double vision, blurred vision, blind spots, flashing lights, floaters, glaucoma, or cataracts.
Ears: Denies hearing problem, tinnitus, vertigo, earaches, infection, or discharge.
Mouth and throat: Patient stated that his teeth are in good condition, without staining, or cavities. Last dental visit for cleaning x 3 months ago; has follow up in 3 months. Denies bleeding gums, lesion in mouth or tongue, altered taste, dysphagia, sore throats, hoarseness.
Respiratory: Denies cough, hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Last PPD 5/2016 with negative result.
Cardiac: History of hypertriglyceridemia since age 46. Denies history of hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Last EKG done in 2016 (normal result).
Gastrointestinal: Admits to lower mid abdominal pain for 2 days. Pain scale 8/10. The pain is aggravated by moving and repositioning; Took Motrin 400mg PO Q6h PRN, bought over the counter without relief Denies trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching or passing of gas, constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 daily soft brown stool.
Urinary: Admits to hematuria for 2 days. History of left side flank pain 4 days ago. Denies frequency, urgency, nocturia, dysuria, polyuria, oliguria, urinary infections, kidney stones, or incontinence.
Genital: Reports to performing self-testicular exam once a month. Denies hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted infections (trichomonas, chlamydia, gonorrhea, syphilis, hepatitis B or C, HIV, etc.). Heterosexual, single, in a satisfying monogamous relationship with girlfriend of 4 years
Musculoskeletal: History of left side flank pain 4 days ago. Denies muscle or joint pain in the neck, upper extremities, back, lower extremities, swelling, stiffness, arthritis, gout, backache, limitation in range of motion, etc.
Neurologic: Denies changes in mood, attention, or speech; changes in orientation, memory, insight, or judgement; headache, dizziness, vertigo, fainting, blackouts, weakness, paralysis, numbness or loss of sensation, seizures, tingling, “or pins and needles” tremors or other involuntary movements.
OBJECTIVE DATA (O)
Skin: Warm and moist with normal turgor. No rash, lesions, ulcers or unusual bruising. Hair: short and black with wavy texture; equal distribution and without hair loss. Nails: pink with capillary refill < 3 sec. No clubbing.
Head: Normocephalic/atraumatic. Fine hair texture, evenly distributed; scalp clean without lesions, tenderness, or lump; right and left side of the face – symmetrical.
Eyes: Vision 20/20 in both eyes. Conjunctiva pink. Sclera white. Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Visual fields full by confrontation. Disc margins sharp without arteriolar narrowing, AV nicking, hemorrhage, exudates, cotton wool spots, or papilledema.
Ear: No lesions or edema of external ears, manipulation of the pinna without tenderness. Ear canals clear, no cerumen observed; and tympanic membrane pearly grey with good cone of light bilaterally. Acuity good to whispered voice. Rinne test AC > BC. Weber –midline (normally the sound is heard in the midline or equally in both ears (If nothing is heard, try again, pressing the tuning fork firmly because patient with normal hearing may lateralize. Therefore, this test should be restricted with to those with hearing loss).
Mouth and throat: Oral mucosa pink and moist without lesions. Teeth intact without cavities. Gum pink without swelling, redness, bleeding, or lesions. Tongue intact and midline. Uvula midline. Tonsils present, no exudates, swelling, or redness. Pharynx without erythema or exudates.
Anterior/Posterior thorax and lungs: Symmetrical, no deformity, no retraction, equal bilateral chest expansion. Respiratory rate 18 cycles per minute. No tenderness on palpation of the anterior and posterior chest. Percussion notes: Resonant; relative intensity – loud; relative pitch – low; relative duration – long. Vesicular breath sounds auscultated over most of the lungs (anterior and posterior chest). No crackles, rhonchi, or wheezing.
Breast, axillae, and epitrochlear nodes: Symmetrical bilaterally, nipples everted, no thickening of the nipples, no mass, tenderness, or discharge; axillary and epitrochlear nodes non palpable.
Cardiovascular system: No increase carotid pulsation on inspection; palpation of the carotid pulses WNL; no carotid carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; JVP-6 CM H2O. PMI auscultated in the 5th left intercostal space (LICS) in the midclavicular line. Heart sound one (S1) and heart sound two (S2) – normal; regular rate and rhythm WNL. No murmurs, S3, S4, rubs, heaves, or gallops.
Abdomen: Protuberant, no scars (if scars present describe location and measurement). Bowel sounds active in all four quadrants; abdominal guarding, Percussion note tympanic in all four quadrants (except the suprapubic area; unable to percuss due to tenderness). Moderate to severe tenderness on light and deep palpation in the suprapubic area; other areas of the abdomen nontender. Liver and spleen palpable and nontender. Kidneys non-palpable.
Genital: Patient declined.
Rectal: Patient declined.
Peripheral vascular system: Brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis pulses brisk (2+) bilaterally. No rashes, swelling, cyanosis, color change, temperature change, shiny skin, or varicose veins in legs.
Musculoskeletal: Full range of motion of the neck and upper extremities; back and lower extremities. Muscle tone and strength 5/5 bilaterally. Normal gait and station. No deformities, crepitation, tenderness, masses, effusion, or atrophy.
Neurologic system: Oriented to person, place, and time. Thought coherent. Cranial nerve 2 – 12 intact. Rapid alternating movements and point-to-point movements intact. Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg test negative. Biceps, triceps, brachioradialis, patellar, Achilles, and plantar reflexes brisk (2+) bilaterally.
– Acute glomerulonephritis
– Urinary tract infection
– Renal cell carcinoma
– Abdominal aortic aneurysm
– Biliary colic
– Musculoskeletal inflammation or spam
(1) Urine dipstick performed at the clinic (Results: Blood positive, pH 7.8, specific gravity 1.021, protein negative, ketone negative, leukocyte esterase negative, nitrite negative, glucose negative, bilirubin negative, urobilinogen negative).
(2) Urine sample sent to the lab for urinalysis (check for presence of crystals).
(3) Renal & bladder ultrasound STAT order sent to the nearby imaging center.
B. Medication management:
– Percocet 5 mg/325 mg one tablet PO every 6 hours for 5 days as needed for pain.
(2) Some of the signs and symptoms of nephrolithiasis include flank pain, pain that spreads to the lower abdomen and groin, pain while urinating, pink/red/brown urine, nausea, vomiting, and fever/chills if an infection is present.
(4) Will be called as soon as the ultrasound result is available.
(6) Small kidney stones may pass out on its own in the urine; however, larger ones may require procedures such as shock wave lithotripsy to break them into smaller pieces, ureterostomy, or percutaneous nephrolithotomy to surgically remove kidney stones.
(8) Take Percocet 5 mg/325 mg every 6 hours as ordered.