HISTORY  

Identifying Data: 

Full Name: CW

Address: Queens, NY 

Date of Birth: 8/23/1971, 50 years old

Date and Time: 1/23/2022,

Location: NYP Queens 

Sex: Female

Race: Asian

Marital Status: Married 

Source of Information: Self  

Reliability: Reliable  

Source of Referral: Self 

PMD: Pt denies having PMD

Chief Complaint: “right flank pain” x this morning

HPI: 

CW is a 50 y/o female with no PMH who presented to the ED ℅ right flank pain since 7:00 AM this morning. She described the pain as sharp, constant, 10/10 severity, and radiating to the right lower abdomen, which is worsening, and accompanied by nausea and 2 episodes of vomiting. She also stated she had no appetite, did not eat anything all day. Pt stated the pain began suddenly when she woke up this morning, with no trauma or events leading up to the pain. She denied any aggravating or alleviating factors, denied taking anything to help with the pain. Pt stated she had a similar episode 3 months ago which resolved with rest, but this time the pain is worse. Pt denied h/o kidney stones, fever, chills, headaches, CP, SOB, hematuria, diarrhea or constipation. 

Past Medical History 

PMH – none

Immunizations – Immunizations up to date- flu vaccine October 2021, COVID 2^nd vaccine April 2021, no booster, Tdap 4 years ago

Screening Tests and Results – none.  

Past Surgical History 

None 

Denies past injuries or blood transfusions.  

Medications-none 

Admits to taking womens multivitamin, unknown type.

Denies taking any OTC’s, or herbal medications

Allergies 

No known drug, food, or seasonal allergies.  

Family History 

Father- cancer of unknown type

Denies any other family history of any illnesses or cancer

Social History 

Pt is a married female who lives in a house in Queens, NY, with her family. Pt does not work. She is currently sexually active with her husband only and denies any past hx of STI’s.

Habits- Pt denies ETOH use, smoking, use of e-cigarettes, or illicit substance use. 

Travel – Denies any recent travel or sick contacts.  

Diet – Pt states she eats yogurt or toast for breakfast, and rice, noodles, and various meat and vegetables for lunch and dinner.

Exercise – Patient states she exercises regularly and walks for about 30 minutes every day.

Sleep – Pt states she sleeps for about 7 hours per night and generally sleeps well throughout the night.  

Review of Systems – 

General – Admits to generalized weakness and fatigue. Denies unintentional weight loss, fever, chills, or sweats.

Skin, Peripheral Vascular – Denies changes in skin texture/temperature, ulcerations, discolorations, rashes, erythema, or pruritus. Denies intermittent claudication, pallor, paresthesia, numbness/tingling, or edema.  

Head & Neck – Denies any headaches, lightheadedness, LOC, or head trauma. Denies visual disturbances, photophobia, sore throat, neck stiffness/mass. 

Pulmonary – Denies SOB, cough, hemoptysis, wheezing

Cardiovascular – Denies chest pain, syncope, or edema. 

GI – Admits to nausea and vomiting. Denies hematemesis, constipation, dysphagia, eructation, rectal bleeding, blood in stool, or abnormal color/odors of stool.  

GU –Admits to right flank pain. Denies urinary frequency or urgency, oliguria, polyuria, dysuria, flank pain, nocturia

MSK – Denies any muscle/joint pain

Hematological – Denies easy bruising or bleeding, lymph node enlargement, blood transfusions.

Endocrine – Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, excessive sweating, goiter.

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

Neurological – Denies any changes in memory/cognition, weakness, abnormal or uncontrollable movement, unsteady gait, or LOC. 

Vital Signs (1/23/22 19:25→ 21:44)

BP 144/73 (left arm, supine) → 157/82

HR 76 rrr → 88

Temp 36.5 C (oral) → 36.3

SpO2 100% on RA → 94%

RR 18 unlabored → 20

Height 63 in.            Weight 58.5 kg                           BMI 22.79

PHYSICAL EXAM 

General – Well-developed female, A/O x3, tearful and in moderate painful distress, well-groomed with good hygiene, looks appropriately her stated age of 50. The patient is resting supine in ER bed.

Skin – Skin is warm and dry with no diaphoresis. Good turgor. No wounds, masses, ulcerations, discolorations, rashes, bruises, pruritus. 

HEENT – Head is normocephalic, atraumatic, and nontender throughout. PERRLA, sclera white with no icterus, cornea and conjunctiva clear, full visual fields, EOMs intact. Mucous membranes are pink and moist, with no signs of cyanosis. No exudates, erythema or swelling of pharynx.

Neck  –  Supple with no masses, tenderness, thrills or bruits, FROM.  

Heart – regular rate and rhythm, carotid pulses are 2+ bilaterally with no bruits, no JVD. S1 and S2 distinct with no murmurs, rubs, or gallops.

Lungs – Lung sounds clear bilaterally all fields, with no wheezing, rhales, or rhonchi. Respirations are normal and unlabored with no accessory muscle use.  

Abdomen –Abdomen has no scarring appreciated,soft, non-distended, and non-tender to palpation in all 4 quadrants with no guarding or rebound, no palpable/pulsatile masses, (+) right sided CVA tenderness and right flank pain. Tympanic to percussion throughout, bowel sounds are present and normoactive throughout all 4 quadrants.  

Pelvic/ GYN Exam- no lesions/ scarring of vulva, no vaginal bleeding or discharge,  non-friable cervix with no blood or discharge protruding from os, non-tender to palpation of bilateral adnexa, no masses appreciated

Rectal – deferred

Extremities – 2+ peripheral pulses. No edema, clubbing, cyanosis, or ulcerations. Full ROM

Psych – A/O x 3, no agitation.  

Neuro – No focal deficits, no gait abnormalities 

DIFFERENTIAL DIAGNOSIS 

1. Right-sided nephrolithiasis
2. Pyelonephritis
3. Retroperitoneal hemorrhage Angiomyolipoma

LABS 1/23/22 @ 17:07

CBC :

WBC- 10.93

Hemoglobin/ Hematocrit- 7.5/25.1

MCV-74.0 

MCH- 23.7

RDW- 21.4

RBC-3.04

Platelets-283

Electrolytes

Na- 139

K-3.3

Cl-102

CO2-26

BUN–13.3, Cr-.51

Glucose- 177

Anion Gap–11

Calcium– 8.8

Magnesium- 1.7

Phosphorus-2.6

Liver Function Tests:

Protein-5.2

Albumin- 3.1

Globulin-2.1

Total bilirubin-0.5

Direct bilirubin-0.2

Indirect Bilirubin-0.3

AST-63

ALT-63

Alkaline Phosphatase-69

Coags:

PT-15.9

PTT-25.3

INR–1.02

Urinalysis

Urine turbid, red

RBC’s>100

WBC’s- 14

Hyaline Casts-present

Urine protein- 100

Urine blood-large

COVID – negative, 1/23/22 

IMAGING/TESTS  

CT Abdomen and Pelvis with and without IV contrast:

FIndings: large right retroperitoneal hemorrhage in the region of the right kidney with multiple areas of active extravasation. Etiology of hemorrhage is uncertain. If no history of trauma, hemorrhage may be secondary to a ruptured right renal mass such as angiomyolipoma given left renal angiomyolipomas and fat density within the hemorrhage. 

Enhancing mass in right kidney superior pole up to 2.4 cm concerning for malignancy. 

Two left renal angiomyolipomas measuring up to 9.2 cm, additional 1.6 cm mass in left kidney pole, which may also represent angiomyolipoma.

Complex cyst in left kidney superior pole with septations.

Recommend  MRI with contrast for further evaluation. 

DIAGNOSIS: Retroperitoneal hemorrhage/ angiomyolipoma

ASSESSMENT 

50 y/o female with no PMH who presented to the ED ℅ right flank pain since 7:00 AM this morning. CTAP showed a large right retroperitoneal hemorrhage in the right kidney with multiple areas of extravasation. 

PLAN 

1. Retroperitoneal hemorrhage/ angiomyolipoma
   1. Start urgent transfusion in ED with 1 unit RBC stat
   2. Admit to Urology team under Dr. Wang, IR for emergent embolization 
   3. Monitor H/H, monitor vitals closely
   4. NPO
   5. IV fluids- D5W and NaCl .45% with KCl 20 meQ/L 75 mL/ hr IV continuous
   6. Pain control- acetaminophen 975 mg Q6H PRN, morphine 2 mg IV Q4HPRN
   7. Antibiotics- Zosyn 4500 mg in 100 mL D5w, IV, Q8H
   8. Strict bed rest
2.  DVT prophylaxis with SCD’s (Sequential Compression Device)
3. Disposition- admit to SICU or step down bed