Diagnosis: Urinary Calculi
Differential Diagnosis: Appendicitis, and Cholecystitis
Include ICD-10 Code for diagnosis
Attached is template. use template exactly they way it is. Be sure to bold abnormal findings.
References no older than 3 years
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THE HISTORY AND PHYSICAL (H&P)
- Chief Complaint
“I normally experience severe, excruciating, and intermittent pain during urination. I also have difficulty passing urine. The small amount of urine that comes out is usually reddish in color.”
- History of Present Illness (HPI)
H.S. is a 54-year-old white male who has reported to the clinic complaining of dysuria or severe pain during urination. The patient describes the pain as excruciating and intermittent. The pain is also characterized by a reduction in the amount of urine produced. However, the patient indicates that the small amount of urine that comes out is normally reddish in color. H.S. further reports that the pain lasts for about 20 minutes and comes again the next time he wants to pass urine. These symptoms began a month ago.
Location: Genitourinary system.
Quality: Excruciating and intermittent pain.
Quantity or severity: Severe pain.8/10 on the pain scale.
Timing: The pain lasts for about 20 minutes. It has lasted for 1 month.
Setting: During urination.
Aggravating or relieving factors: The pain is worsened when the patient lies down.
Associated manifestations: Hematuria or blood in urine, nausea, fever, chills, vomiting.
III. Past medical history (PHx)
- Childhood illnesses
Medical records indicate that H.S. had measles at the age of four years and he was treated without hospitalization.
- Immunizations
The patient was fully immunized against diphtheria, pertussis, and tetanus (DPT) during childhood. The last tetanus booster was given at the age of 12 years. He lastly received influenza vaccine at the age of 20 years. H.S. got his first dose of COVID-19 vaccine (AstraZeneca) four months ago.
- Adult Illnesses
H.S. was diagnosed with malaria and mild headache repeatedly during adulthood. However, he was treated without requiring hospitalization.
- Operations
He denies undergoing any surgical procedure before.
- Allergies
Denies drug or food allergies.
- Medications
Denies medication use at the moment.
- Complimentary treatments
H.S. is not under any complementary treatments
- Family history
H.S.’s father is 78 years old. He suffered ischemic attack at the age of 68 years and he is still using medications to manage the condition. His mother, currently aged 74 years was diagnosed with high blood pressure 5 years ago. Her blood pressure is well-controlled at the moment. H.S. has two sisters aged 47 and 37 years. He also has a brother aged 42 years. His sisters and brother are all healthy. H.S. has a daughter and a son aged 24 and 30 years respectively. Both of them are healthy.
- Social history
H.S. has diploma in accounting. He is working as an accountant in a nearby manufacturing company. He is a middle-income earner. He stays with his wife at home. He rarely travels away from home. H.S. consumes neither alcohol nor cigarettes. He denies using illicit drugs such as cocaine or heroin. H.S. is sexually active. He reports being faithful to his wife. H.S. has reported that he consumes cocoa every day in the morning and at night before going to bed. His favorite vegetable is spinach and he reports including it in his diet about three times per week. He also consumes a lot of pepper.
- Review of Systems
General: Reports a slight reduction in body weight of about 1 pound in the past month. Reports nausea, vomiting, and chills, and fever. Admits experiencing severe pain in the genitourinary system during urination. According to H.S., his last physical examination was in December 2019.
Skin: Denies bruises, pruritus, redness, or rashes on the skin. Refutes hair loss or thinning. Denies brittle nails or nail breakage.
HEENT:
Head: Denies head injury, no headache.
Eyes: Denies redness and pain in the issues. Denies vision issues. The last date of eye examination was in December 2019. Denies a history of glaucoma or cataracts. He does not use contact glasses.
Ears: Does not report ear pain, hearing loss, ear infection, or hearing in the ears.
Nose and sinuses: Does not report nasal stuffiness, denies nasal discharge or obstruction. Denies changes in smell. No history of nasal polyps reported.
Mouth and throat: Denies mouth pain, dryness, or mouth ulcers. Does not report hoarseness of the throat. Denies a history of bleeding gums or strep throats.
Neck: Does not report pain. Denies swollen lymph nodes. Denies neck lumps or goiter.
Lymphatics: Does not report axillae or swollen lymph nodes on the neck area.
Breasts: Does not report nipple discharge, pain, or discomfort from both breasts. No masses or lumps reported.
Pulmonary: Does not report a cough. Denies trouble breathing. Denies hemoptysis. No pleuritic chest pain reported. No wheezing reported. Denies cyanosis. Denies a history of tuberculosis or recurrent pneumonia.
Cardiovascular: Does not report any previous cardiovascular complications. Denies chest pain, shortness of breath, irregular heartbeat, or heart murmurs. Denies a history of rheumatic fever or high blood pressure.
Gastrointestinal: Reports pain in the lower abdominal region during urination. Denies dysphagia, heartburn, or indigestion. Reports vomiting or nausea. Denies changes in bowel movements. Denies diarrhea, constipation, excessive belching, or a history of jaundice and gallbladder problems.
Urinary: Reports pain in the genitals during urination (dysuria). Reports the presence of blood in urine (hematuria). Reports a reduction in urine volume. Denies a history of urinary tract infections.
Genital tract (male): Does not report a history of a sexually-transmitted disease (STD). Denies infertility or impotence. Reports pain characterized by obstruction in the ureter. Does not report swelling in the testicles. Denies penile discharge or hernias.
Musculoskeletal: No joint pains or stiffness reported. Denies joint swelling, joint tenderness, backache, limitations of motion, or a history of fractures.
Neurologic: No seizures or blackouts reported. Denies tingling, tremors, or numbness of limbs. Does not report headaches, dizziness, muscle atrophy, or changes in memory.
Psychiatric: No depression, anxiety, insomnia, nervousness, or tension reported. H.S. denies suicidal ideation or a history of self-harming behaviors.
Endocrine: Does not report heat intolerance. Denies excessive thirst, abnormal sweating, or excessive hunger. No thyroid trouble reported. Denies excessive urination.
Hematologic: H.S. does not report anemia, abnormal bleeding, or easy bruising. Denies a history of past blood transfusions.
VII. Physical examination
Vital signs: Blood pressure; 120/80, temperature; 36.2 degree Celsius, pulse; 92 beats per minute, respiratory rate; 20 breaths per minute, weight; 198.5 pounds.
General appearance: H.S. looks tired and worried from his condition. He is neatly dressed, well-groomed and attentive. He is oriented to time, place, and person.
Skin: Skin is warm, intact, and dry without rashes, sores or lesions. No evidence of cyanosis of the nail beds.
HEENT:
Head: The head is atraumatic and normocephalic. No palpable masses, scarring, or depressions. Hair is evenly distributed on the scalp and of normal texture.
Eyes: Eyelids are normal in appearance without swelling or lesions. Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric.
Ears: The ear canal is clear without discharge. No evidence of blockage. The external ear and ear canal are without edema and are non-tender. The tympanic membrane is pale grey in color.
Nose: Nasal mucosa is hairy, pink, and moist. No evidence of nasal hemorrhage. The nasal septum is positioned midline.
Throat: Oral mucosa is without sores, lesions, or ulcers. It is pink and moist with good dentition. The pharynx is pink in appearance with no evidence of tonsillar exudates or edema.
Neck: Trachea is positioned midline. No unusual masses or pulsations. Supple without bruits or lesions.
Nodes: No evidence of swelling of the inguinal, axillary, and epitrochlear nodes.
Chest: Normal breath sounds noticed. No wheezes, crackles, rubs, or rhonchi.
Heart: Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. No noise on a bilateral basis. Midclavicular PMI visible, 5th intercostal region, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.
Abdomen: No scars, no bowel sounds. Lower part of the abdomen is somewhat tender.
Back/spine: No evidence of deformity on the neck and back, external skin changes, or signs of trauma. Gait is smooth, posture is upright, and steady, within normal limits.
Extremities, including exam of pulses: No evidence of trauma in the upper and lower extremities. Palpable pulses observed.
Genitalia/Rectal: No penile lesions, pubic hair evenly distributed. No external masses or lesions. Evidence of suprapubic pain on touching.
Neurologic:
Mental status: H.S. is attentive and able to concentrate. Has a good level of consciousness. No evidence of language, speech, or memory issues.
Cranial nerves: Full EOM’s on crania nerves II-IX. The nerves are intact. Visual fields observed.
Motor: Normal gait, good balance, no evidence of muscle rigidity. Muscle strength on all joints is 5/5.
Sensory: Lower and upper limbs are sensitive to touch and pricking. Reflexes are 2+.
VIII. Problem list
Patient H.S. is a 54-year-old white male who has reported to the clinic complaining of severe, excruciating, and intermittent pain during urination which has lasted for the past one month. He also has difficulty passing urine. The patient has reported that the small amount of urine that comes out is usually reddish in color. The problematic symptoms that should guide the clinician when making a decision regarding the patient’s diagnosis include dysuria or severe pain, which is excruciating and intermittent, during urination. Additional symptoms include difficulty passing urine, hematuria, nausea, fever, chills, vomiting, pain in the ureter that last for 20 minutes, reduced urine volume, and pain that radiates to lower regions of the abdomen during urination. Evidence of ureter obstruction, tenderness in the lower abdomen, and evidence of suprapubic pain on touching should also guide decision-making.
- Differential diagnosis
- Urinary calculi (primary diagnosis)
ICD 10 code: N20.9: Urinary calculus, unspecified
- Appendicitis
ICD 10 code: K37: Unspecified appendicitis
- Cholecystitis
ICD 10 code: K81: Cholecystitis
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Bickley, L. (2018). Bates guide to physical examination and history taking (12th ed.). Philadelphia, PA: Wolters Kluwer.
Mayo Clinic. (2020). Cholecystitis. https://www.mayoclinic.org/diseases-conditions/cholecystitis/diagnosis-treatment/drc-20364895
Rachna, J. & Yogesh, J. (2021). The importance of physical examination in primary health care provided by NPHW is being threatened in COVID19 times. Journal of Family Medicine and Primary Care, 10(1), 19-21 doi: 10.4103/jfmpc.jfmpc_1932_20
Snyder, M. J., Guthrie, M., & Cagle, S. (2018). Acute appendicitis: Efficient diagnosis and management. American Family Physician, 98(1):25-33. PMID: 30215950.
Urology Care Foundation. (2021). Kidney stones. https://www.urologyhealth.org/urology-a-z/k/kidney-stones.