ED General Note

ID

• Arthur Pendelton is a 42-year-old male.

CC

• Right flank pain.

HPI

• Sudden onset severe right flank pain starting at 06:30 today (14/05/2024). Pain is sharp, colicky, 9/10 intensity, radiating to the right groin. Associated with nausea and 2 episodes of non-bilious, non-bloody emesis. Positive for gross hematuria noticed once this morning. Denies fever, chills, dysuria, testicular pain, or abdominal trauma.

PMHX

• HTN, prior nephrolithiasis (passed spontaneously 4 years ago), appendectomy (2010).

MEDS

• amlodipine (Norvasc®) 5 mg PO daily.

ALLERGIES

• NKDA

FAMILY HISTORY

• Father has history of nephrolithiasis and T2DM.

SOCIAL HX

• Non-smoker, social EtOH (2-3 beers/week), works as an accountant, lives with spouse.

PHYSICAL EXAM

T 36.8 °C, HR 94 bpm, BP 148/92 mmHg, RR 18/min, SpO2 99 % on RA. Alert, oriented x3, writhing on stretcher in moderate distress secondary to pain. T 36.8 °C, HR 94 bpm, BP 148/92 mmHg, RR 18/min, SpO2 99 % on RA.

HEENT: Normocephalic, atraumatic, mucous membranes moist, PERRLA.

Neck: Supple, no JVD, no lymphadenopathy.

CVS: normal S1 / S2, no S3/S4 or murmurs

Resp: chest clear to auscultation, no crackles / wheezes, no crepitus

Abdomen: soft, non-tender, no peritonitis or guarding, no masses

Extremities: No peripheral edema, pulses 2+ bilaterally, calves soft and non-tender.

Back examination (ASIA scale):

General: ASIA Grade E (normal motor and sensory function).

Tenderness to palpation to: Right costovertebral angle. Bruising: none Scars: none

INVESTIGATIONS

• Urinalysis: Large blood, negative leukocyte esterase, negative nitrites. CBC: WBC 8.2 x 10^9/L, Hb 148 g/L, Plt 240 x 10^9/L. Chemistries: Na 139 mmol/L, K 4.1 mmol/L, Cr 88 umol/L, eGFR 92 mL/min. CT KUB (non-contrast): 4 mm obstructing calculus at the right vesicoureteric junction (VUJ) with mild right hydroureteronephrosis, no perinephric stranding.

REASSESSMENT

Reassessment at 09:45 due to a change in condition / treatment plan. Re-examined: Abdomen and right flank. Patient reports pain has decreased to 1/10 following IV analgesia; abdomen remains soft and non-tender, tolerating PO fluids without further nausea or vomiting. Plan changed: Clinically stable and comfortable, cleared for discharge home on medical expulsive therapy.

IMPRESSION / PLAN

• Impression: Acute right renal colic secondary to 4 mm distal ureteric calculus at the right VUJ. Differential diagnosis of pyelonephritis or ruptured AAA excluded. Treated in ED with ketorolac (Toradol®) 30 mg IV once, ondansetron (Zofran®) 4 mg IV once, and normal saline 0.9 % 1,000 mL IV bolus.
• Plan: 1. Start tamsulosin (Flomax®) 0.4 mg PO daily for 14 days. 2. Take naproxen (Naprosyn®) 500 mg PO BID PRN for pain with food. 3. Take paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q6H PRN for pain. 4. Strain all urine to capture stone for analysis. 5. Follow up with Family Medicine Specialist in 1-2 weeks for repeat imaging and renal function check.
• Referrals: Outpatient Urology referral if stone does not pass within 4 weeks.
• Discharge Criteria: Pain controlled on oral analgesia, tolerating oral fluids, normal renal function, afebrile.
• Reasons to return to the emergency department: Return immediately for fever, chills, intractable pain, persistent vomiting, or inability to pass urine.

“The patient gave verbal consent for use of an AI scribe during this visit, acknowledging its purpose, possible benefits, and related privacy and security risks.”