H&P

History

Identifying Data:

Full Name: K.J.

Address: N/A

Date of Birth: N/A

Date & Time: 2/14/2023, 11:40 am

Location: Queens Presbyterian Hospital 

Religion: N/A

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: N/A

Chief Complaint: “I’m here because I’ve been having blood in my urine since Sunday.”

History of Present Illness:

71 year old male with PMH of BPH, HLD, intermittent hematuria, presenting for hematuria since Sunday. Patient states that he also noted clotting along with passage of dark red blood that started Sunday as well. He notes that this has been continuous since then but has still been able to completely void without issues. Patient also reports slight dysuria that he rates a 4/10. Patient was last seen by his urologist Dr. Gerald Wang yesterday in office where he had a renal ultrasound done which was reported unremarkable. After being seen, the patient complains on continued hematuria today and came to the ED for further evaluation. He denies any fever, chills, nausea, vomiting, diarrhea, or any other irritative voiding symptoms.

Initial DDx:

• BPH
  • BPH can recur even after having prostate surgery and BPH itself can cause hematuria, although it is usually microscopic. Patient stated he had 2 prostate surgeries already in 2012 and 2016.
• Hematuria secondary to TURP for BPH
  • Mr. K.J. has had two prostate surgeries. Upon research, I found that one of the complications of a procedure like TURP can result in episodes of gross hematuria. In addition, the patient denies any fever, chills, abdominal, pelvic, or flank pain indicating any ongoing infection. 
• Acute Cystitis
  • Cystitis can cause hematuria and the patient does complain of slight dysuria. Patients with cystitis are also usually afebrile which the patient is in this case.
• Kidney stone
  • Kidney stones can cause dysuria and gross hematuria with pain or occasionally without pain, but patient denies any abdominal or pelvic, or unilateral flank pain, fever, or chills.
• Pyelonephritis
  • Pyelonephritis is less likely as the patient has no fever, flank pain, chills, vomiting or malaise.

Past Medical History:

Hyperlipidemia x 20 years, on medication, but patient unable to recall the name and I was unable to locate in his chart

BPH x 8 years, not any medications

Childhood Illnesses- N/A

Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent Sept. 2022)

Screening test and results – Screening colonoscopy 2014, benign.

Past Surgical History:

Prostate Surgery, 2012 & 2016

Denies any blood transfusions.

Medications:

Hyperlipidemia medication (name and dosage unknown)

Denies use of herbal supplements.

Allergies:

NKDA

Family History:

Mother – Deceased at 80

Dad – Deceased at 85

Children – Alive and well

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons 

Family history of cancer. Denies family h/o diabetes and myocardial infarctions.

Social History:

Mr. K.J is married. Lives with his wife.

Habits – Denies tobacco use. No history of alcohol abuse, denies history of illicit substances. Drinks 1cup of tea a day.

Travel – No recent travel.

Diet – He states he has a well-balanced diet.

Exercise – Exercises 1-2 x week.

Safety measures – Admits to wearing a seatbelt.

Sexual Hx – Pt is heterosexual. He is sexually active.

Denies history of sexually transmitted diseases.

Review of Systems:

General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution. 

Head – Denies headache, vertigo, or head trauma. 

Eyes – Denies lacrimation, pruritus, visual disturbances or photophobia. Does not wear glasses. Does not recall when his last eye exam was or what his visual acuity or pressure is.

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

Nose/sinuses – Denies discharge, epistaxis, or nasal polyps.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Does not recall when last dental exam was.

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

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation. Colonoscopy 2014, benign. 

Genitourinary system – Admits to dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain. 

Menstrual/Obstetrical – N/A

Musculoskeletal system – Denies muscle/joint pain from rheumatoid arthritis. Denies deformity or swelling, or redness.

Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness. 

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes. 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter 

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional. 

Physical

General: Male appears clean & well-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. No signs of acute distress, appears as stated age.

Vital Signs:     BP: (R) Seated 143/79                        P:  91 beats/min, regular

                               (L) Seated 138/80

                        R: 14 breaths/min, unlabored             O2 Sat: 95% Room Air

                        T: 36.4 degrees C (oral)

                        Height: 66 inches        Weight: 150 lbs          BMI: 24.2

Head, Skin, & Nails

Hair: Average quantity and distribution. White color. Straight texture. No evidence of lice or seborrheic dermatitis.

Skin: Warm and moist, smooth texture, good turgor. 

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Eye Exam

Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/30 OS, 20/30 OD,  20/30 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.

Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, exudates or neovascularization OU.

Ear Exam

Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.

Nose & Sinuses Exam

Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.

Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth & Pharynx

Lips –   Pink, moist; no cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink ; well hydrated. No masses; lesions noted.   Non-tender to palpation. No leukoplakia. 

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  Non-tender to 

            Palpation; continuity intact. 

Teeth – Good dentition / no obvious dental caries noted. 

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. 

Tonsils present with no injection or exudate. Uvula pink, no edema, lesions

Neck Exam

Neck– Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to

palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted. 

Thorax & Lungs:

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.

Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Cardiac Exam

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

Abdominal Exam: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebounding noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge. 

Pelvic Exam:

Genitalia: 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, but enlarged.

Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally. 

Reflexes:

	Biceps	Triceps	Brachioradialis	Patellar	Ankle/Achilles	Babinski
Right	2+	2+	2+	2+	2+	absent
Left	2+	2+	2+	2+	2+	absent

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /

ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

DDx after H&P: 

• Hematuria Secondary to BPH

Labs:

• CBC
  • RBC 4.39
• BMP – unremarkable
• Urine analysis & Culture
  • Color – Red
  • Blood – large
  • Leukocyte esterase – small
  • RBCs >100
• Type & screen
• COVID-19: negative

Imaging:

• Renal & bladder ultrasound – unremarkable

Assessment: 71 y/o male w/ PMH of BPH, HLD, intermittent hematuria, presenting for hematuria since Sunday. Physical exam unremarkable. Will obtain CBC with differentials, BMP, Urine Analysis & Culture, Type & Screen, renal and bladder ultrasound, and Urology consult for evaluation of continuous bladder irrigation. Will also place peripheral IV for fluids.

Plan: Discussed findings, diagnosis and treatment plan with patient. Based on urology consult and given that patient is voiding without issues in ED, patient is stable for discharge and should follow up outpatient with Dr. Wang, his urologist for further evaluation and treatment. Patient advised to return for any worsening symptoms.