History
Identifying Data:
Full Name: Mr. M
Address: Flushing, NY
Date of Birth: January 29, 1941
Date & Time: February 10, 2023
Location: NYP- Queens
Religion: Christian
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief complaint: “I have blood in urine” x 1 day
Patient is a 82 year old male with a PMHx of HTN and BPH and PHSx of hernia repair who presents with progressively worsening hematuria x1 day. Reports he noticed he started to pass large blood clots on his urine which prompted his visit. Denies aggravating factors, associated pain or attempting any treatments. Reports the hematuria has been constant. States he was able to void prior to coming to the ED. (time frame from last and quantity, is it normal void)) Reports he had a similar episode 12 to 13 years ago for which he followed up with Urologist was diagnosed with BPH , prescribed FInasteride. States he has been compliant with his medication. Since then he has had 3 biopsies of his prostate which have been normal. His last follow up with a Urologist Dr. Richardi was July 2022 when he had an MRI which was normal. He denies flank pain, dysuria, chills, fever, rectal pain, nausea, vomiting, diarrhea, chest pain, palpitations, dizziness, lightheadedness, use of blood thinners, history of STIs.
ED course overnight: Patient was unable to void. 22 Fr. 3 way hotter Foley catheter was inserted without difficulty draining blood urine. Foley Balloon inflated with 10cc of sterile water and connected to the drainage bag. Patient tolerated the procedure well and there were no complications. ( amount of last voiding & residual urine) Patient initially noted with light punch urine, worsening to dark punch color. Irrigated with 2 Liter with evacuation of 200cc of clots, cleared up to light pink. Patient started on CBI
Past Medical History:
Hypertension
BPH
Past Surgical History:
(open or laparoscopic) Hernia Repair in 2015 at Queens Hospital Center, unknown surgeon
Social History:
Denies EtOh or Substance abuse. He lives at home with his wife and is retired.
Family History: Denies history of cancer
Immunizations: Up to date
Medications:
Diltiazem HCl ER beads 240 mg Daily Orally
Finasteride 5 mg 1 tablet daily Orally
Valsartan 320 mg 1 tablet Daily Orally
Isosorbide mononitrate ER 30 mg 1 tablet Daily orally
Activities of daily living:
Independent in ADLs
PMD: Dr. Johaira L Dianalan, MD
Urologist: Dr. Riccardo Ricciardi
(VaccinesScreening questions)
Review of Systems:
General: Denies generalized weakness, any fever/chills, diaphoresis, weight loss, or night sweats.
Skin, hair and nails: Denies excoriations, itching and jaundice
Head: Denies any headache, vertigo, head trauma, unconsciousness, coma or factures.
Eyes: Denies any visual disturbances.
Ear: Denies pain, discharge, tinnitus.
Nose: Denies any discharge, epistaxis or obstructions.
Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers.
Neck: Denies any localized swelling/lumps, stiffness, or decreased range of motion.
Pulmonary: Denies cough, dyspnea, wheezing, hemoptysis, cyanosis, orthopnea, or PND.
Cardiovascular System: Denies chest pain, HTN, palpitations, peripheral edema, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal System: Denies abdominal pain, nausea, diarrhea, vomiting, constipation, rectal bleeding, or blood in stool, dysphagia, pyrosis, unusual flatulence or eructation
Genitourinary System: Reports hematuria. Denies dysuria,hesitancy, weak urine stream, increase frequency, urgency, incontinence, nocturia, oliguria, or flank pain.
Neurologic: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of
strength, change in cognition, mental status, memory, or weakness.
Musculoskeletal System: Admits muscle aches. Denies joint pain, deformity or swelling or redness.
Hematologic System:. Denies bleeding or lymph node enlargement.
Endocrine System: Denies polyuria/polydipsia/polyphagia, goiter, excessive sweating, heat or cold intolerance, or hirsutism.
Psychiatric: Denies any hx of abuse, agitation, confusion or changes in behavior.
Differential Diagnosis
- Urinary Tract Infection: Patient presents with hematuria
- Benign Prostatic hyperplasia: Patient presents with hematuria and has PMHx of BPH
- Bladder cancer: Patient presents with painless hematuria
Vital Signs
Blood pressure: 137/72 mmhg
Respiratory rate: 18/min unlabored Pulse: 85
Temperature: 36.6 C SPO2: 95% on room air
Physical Exam
General: Neatly groomed, appears at stated age of 82 years. Alert and oriented x 3, appears to be in mild acute distress.
Skin: warm & moist, poor turgor. No other lesions, scars or tattoos noted.
Nails: no clubbing or cyanosis. Capillary refill < 2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout, no specific facies.
Eyes: Symmetrical OU; no strabismus, exophthalmos, ptosis, edema, inflammation, crusting, or discharge; Sclera white; cornea clear; conjunctiva pink. Visual fields full OU. PERRLA. EOMs intact with no nystagmus.
Neck: Supple, no lymphadenopathy.
Heart: RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses 2+ with no bruits.
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored. Nontender to palpation throughout.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion is symmetrical. No adventitious sounds.
Abdomen: Abdomen symmetric with no striae or pulsations noted. Bowel sounds normoactive. Soft, non distended, non tender. No rebound, guarding or rigidity. No CVA tenderness b/l.
Genitourinary: 22 FR 3 way hotter foley with pink urine draining. Penis: uncircumcised No paraphimosis, Phimosis. Scrotum – no swelling, erythema bleeding or discharge or fluctuance
Musculoskeletal: Full passive and active ROM in upper and lower extremities. No soft tissue swelling, erythema, deformities throughout.
Mental Status Exam: Oriented to person, place, time and situation. Cooperative and pleasant. No dysarthria, dysphonia or aphasia noted.
LABS
PTT/ PT INT
Type/ Screen
Ultrasound Renal/ Bladder Impression:
Minimal left hydronephrosis and fullness of the right renal collecting system.
Prostatomegaly with median lobe hypertrophy.
Distended bladder containing proteinaceous/hemorrhagic debris.
Assessment
82 year old male with PMHx of HTN and BPH who presented with gross hematuria. On physical exam, 22 FR 3 way hotter foley draining pink urine in place with CBI ongoing. Vital signs are stable. Labs significant for CRT of 1.36, HGB/HCT 10.0/31.9 which is downtrending. Potassium is within normal limits after correction . UA is significant for large blood, ketones, protein and small amounts of leukocyte esterase. Ultrasound significant for Minimal left hydronephrosis and fullness of the right renal collecting system and prostatomegaly. He is being consulted Urology service for gross hematuria.
82 hx consulted for hematuria, s/p CBI placement overnight, (findings) US.
overnight –
On AM rounds,attempted to
With evac of another 150 CCs
Procedure note:
Attempted to manually irrigate foley, but unable to aspirate fluid. Patient prepped and draped in standard sterile fashion. Foley was removed and replaced with a 22FR Rusch foley. Manual irrigation was done, 150 CC of clots removed. Urine resumed to a light tinged pink color at the end. Foley was inflated with 40 CCs sterile water. Restarted on CBI.
Plan:
Diet, activity, pain control
- CBI with manual irrigation PRN “ why, time frame, indications for doing it”
- Trend H/H & transfuse if HGB <7 and platelets <50
- IV fluids – Lactated Ringer’s Bolus 1000 mL
- Trend creatinine, unknown baseline
- CT Urography
- Cystoscopy if bleeding is not controlled with CBI
- Urine Cytology to rule out cancer pathology
- Obtain collateral information from Urologist
Code Status: full code
Dispo: to floor
