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    CHF With Obstructive Uropathy

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    John Ortiz
    Dr. Jonathan Ortiz Agundez saw a 78-year-old male patient who presented with 3 months of abdominal pain. His medical history included diabetes, hypertension, peripheral vascular disease, and prior stent placements. On examination, the patient had abdominal distension and tenderness in his right lower quadrant. Diagnostic testing showed signs of obstructive uropathy. The patient was admitted with a primary diagnosis of obstructive uropathy and secondary diagnoses including hydrocele and pleural effusion. Differential diagnoses included various cancers and ureterolithiasis. Admission orders included diagnostic imaging and lab tests as well as medication adjustments and diet changes.

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    CHF With Obstructive Uropathy

    Uploaded by

    John Ortiz
    42 views28 pages
    Dr. Jonathan Ortiz Agundez saw a 78-year-old male patient who presented with 3 months of abdominal pain. His medical history included diabetes, hypertension, peripheral vascular disease, and prior stent placements. On examination, the patient had abdominal distension and tenderness in his right lower quadrant. Diagnostic testing showed signs of obstructive uropathy. The patient was admitted with a primary diagnosis of obstructive uropathy and secondary diagnoses including hydrocele and pleural effusion. Differential diagnoses included various cancers and ureterolithiasis. Admission orders included diagnostic imaging and lab tests as well as medication adjustments and diet changes.

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    Chf With Obstructive Uropathy

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    Dr. Jonathan Ortiz Agundez saw a 78-year-old male patient who presented with 3 months of abdominal pain. His medical history included diabetes, hypertension, peripheral vascular disease, and prior stent placements. On examination, the patient had abdominal distension and tenderness in his right lower quadrant. Diagnostic testing showed signs of obstructive uropathy. The patient was admitted with a primary diagnosis of obstructive uropathy and secondary diagnoses including hydrocele and pleural effusion. Differential diagnoses included various cancers and ureterolithiasis. Admission orders included diagnostic imaging and lab tests as well as medication adjustments and diet changes.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    42 views28 pages

    CHF With Obstructive Uropathy

    Uploaded by

    John Ortiz
    Dr. Jonathan Ortiz Agundez saw a 78-year-old male patient who presented with 3 months of abdominal pain. His medical history included diabetes, hypertension, peripheral vascular disease, and prior stent placements. On examination, the patient had abdominal distension and tenderness in his right lower quadrant. Diagnostic testing showed signs of obstructive uropathy. The patient was admitted with a primary diagnosis of obstructive uropathy and secondary diagnoses including hydrocele and pleural effusion. Differential diagnoses included various cancers and ureterolithiasis. Admission orders included diagnostic imaging and lab tests as well as medication adjustments and diet changes.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 28

    CASE REPORT

    Dr Jonathan Ortiz Agundez


    Medical Intern
    06/24/2021
    Chief Complaint
    • 06/23/2021 7:00 pm
    • “Llevo 3 meses con un dolor abdominal ”
    History of Present Illness
    Case of a 78 year old male patient that comes to ER complaining of RLQ Pain of 3
    months of evolution. Patient and family members have been worried because they
    have been to numerous Internal/Gastro/Urologist which they haven’t found a
    diagnostic. Patient was recently discharged from Damas Hospital 3 days ago. Pain Is
    described as constant pain , 8/10 in intensity , crushing in nature. Pain irradiates
    from hipogastros to R+ flank , movement and coughing increases pain and decreases
    lightly in L+ decubitus lateral position. Patient takes dologesic 500 mg for pain
    management w/o improvement of symptoms. Patient also refers a dry non
    productive cough that started about the same time. Patient refers that 2 weeks ago
    he started feeling bloated , increase in his abdomen size with edema in lower 1/3 of
    bilateral extremities and increase size of his testicles, associated symptoms are
    nausea and vomit with increase in salivation , but denies dizziness , hematuria ,
    urinary retention or fever
    Past Medical History
    • Past Personal history and Medications
    • Diabetes Mellitus type 2
    • Hyperlipidemia
    • Hypertension
    • Peripheral Vascular Disease
    • Benign Prostatic Hyperplasia
    • Old MI with Stent Placement x 3
    Past Medical History
    Medications
    • Metoprolol 25 mg 1 tab 2 times daily
    • Simvastatin 20 mg 1 tab at Night
    • Tamsolusin 0.4 mg 1 tab daily
    • Plavix 75 mg 1 tab daily
    • Tradjenta ( Refuses to take , because of general GI upset)
    Past Medical History
    • Past Family History: Father –( Deceased natural causes 96 years old)
    Mother - ( Deceased, DM type 2 )
    Grandmother ( Stomach Cancer )
    • Allergies: N/A
    • Hospitalizations: Last week in Damas Hospital , MI (2011)
    • Transfusion: None
    • Religion: Jehovah Witness
    • Surgeries- Apendicectomy ( 43 yrs old)/ Stent Placement x3 (2011)
    • Inmunizations: Covid 19 Vaccine , Moderna , March 2021, no reaction
    Social History
    • Social status: Married
    • Sexually active: No, no hx of STD's
    • Occupation: Retired ( Construction Worker / Industrial Mechanic)
    • Education : 4th grade education
    • Exercise: Does not exercise
    • Alcohol: No
    • Smoke: Quit smoking 30 yrs ago (smoked from 14 -48 yrs)
    • Drugs: No
    • Diet: Tries to have a Diabetic Diet, low carb , low salt
    Review of Systems
    • General:
    • Denies: Dehydration , Weight loss, Night Sweats, weakness , fever , chills , fatigue ,
    dizziness, pale skin, no headache
    • Skin:
    • Denies: Ulcers, Infections or Ictericia, Rash or pruritus, no wounds or incisions
    • Hematologic:
    • Denies: Bleeding or anemia in the past , easy bruising
    • HEENT:
    Positive- Nasal Congestion , hypersalivation
    • Denies: Vertigo, recents Trauma, Visual changes, Epistaxis, Sinus Pain, Sore throat,
    Hoarseness, Dysphagia, Tinnitus, erythema , no exudate
    Review of Systems
    • Respiratory
    - Positive – 3 month history of non productive cough
    • Denies: Dyspnea, Sputum, Hemoptysis, Wheezing, Orthopnea or Crackles

    • Cardiovascular:
    - Positive – Peripheral edema
    • Denies: Chest pain, Orthopnea, Paroxysmal Nocturnal Dyspnea, Palpitations, Edema, Syncope, Heart
    Murmur, Varicose Veins, Thrombophlebitis, Tachycardia or Bradycardia

    • Gastrointestinal:
    • Positive: Hemorrhoids, Nausea/vomit , Constipation , abdominal bloating
    • Denies: food intolerance, diarrhea, melena, jaundice, hematochezia, hematemesis, heartburn, cramps or
    vomiting
    Review of Systems
    • Urologic:
    Positive – nocturia , 2 week history of increase in scrotum
    • Denies: Dysuria, Hesitancy, Discharge, Hematuria
    • Musculoskeletal
    • Positive – Low back Pain
    • Denies: Swelling, Trauma, Stiffness, Paresthesias, Lower extremity weakness ,
    Muscle wasting

    • Neurologic
    • Denies: Memory loss, Seizure, Syncope, Tremors, Incoordination, peripheral
    tingling / peripheral numbness
    Review of Systems

    • Endocrine
    • Denies: Polydipsia, Polyphagia, Heat/Cold Intolerance or Goiter
    • Psychological
    Positive – Anxiety and Insomnia
    • Denies: Nervousness, Depression or Irritability
    Physical examination
    B/P MAP HR RR TEMP C SPO2 % WEIGHT HEIGHT BMI
    6:00PM 168/89 115 84 21 36 99% RA 142 pds 5’5 24.3

    10PM 141/80 100 77 16 37.1 99%RA 142pds 5’5 24.3

    • General: Well groomed 78 yr old male, white hair , Active and alert,
    Oriented x 3, well developed, well nourished , talks in complete
    sentences, acutely Ill
    • Skin: Normal turgor , free of eruptions or tumors, hair texture and
    normal distribution
    Physical examination
    • HEENT:
    • H= Normocephalic, atraumatic, No tenderness to palpation, normal ROM
    • E= Extraocular Movements Intact, Pupils equal, round and reactive to light
    accommodation , Conjunctivae and sclera are clear.
    • E= No auditive canal discharge, no tenderness mastoid process, Otoscopy
    exam: No evaluated.
    • N= Nasal discharge, clear hyaline
    • T= Moist Mucous membranes, pink, no cyanosis, no pharyngeal erythema or
    exudates, no thrush, no vesicles , no lesions, good dentition , mouth normal
    with normal lips, tongue , palate , uvula , teeth and gums
    Physical examination
    • Neck: No JVD, No Carotid Bruit, No lymphadenopathy, No thyromegaly, Neck supple,
    good carotid pulse
    Carotid R - 3+ normal pulse , Carotid L- 3 + normal pulse

    • Thorax: Symmetric chest expansion, no diafragmatic or intercostal retractions, no


    deformities or lesions, no dullness to percussion or tenderness to palpation.

    • Heart: RRR, S1-S2 normal, no murmurs or gallops audible

    • Lungs: Base of lungs with decreased breath sounds bilateral, decreased vocal
    fremitus , no wheezing or crackles
    Physical examination
    • Abdomen: BS (+) normal , Globus and distended with abdominal hernia that
    extended from 2 cm below xyphoid process to umbilical area, 20 cm , tenderness
    to palpation and guarding in Right lower quadrant there is a visible scar at
    mcburneys point from past appendectomy horizontal of 10 cm in length, 2 large
    lymph nodes were palpated in RLQ 3 cm under mcburneys point , palpable ,
    movable , painfull to touch approximately 1.5 cm round, No organomegaly to
    palpation, masses, Murphy sign -, Cullen sign and Grey Turner sign .
    • Genitals: There was an increase in size of scrotum, painfull to palpation , R+
    testicle was slightly larger than left , translucency (+)
    • Extremities: bilaterally symmetrical, complete ROM, no cyanosis, no clubbing,
    bilateral peripheral edema lower extremities (+),loss of lower extremity hairs.
    Dorsalis and Posterior tibial Pulses 1+, Radial and brachial pulses +2 .
    Physical examination
    • Neuro: Alert, oriented x3, CNII – CNXII no gross Deficits. No alteration
    to nose-to-finger gait, no Babinski or Romberg sign, Deep tendon
    reflex 2/4.
    Laboratorios
    CBC + DIFF
    BMP
    13.80
    135 95 14
    8.28 426 167
    43.1
    5.50 29 1.20
    DFF: %
    Neutrophiles: 70.3 59
    Lymphocytes: 19.2
    Monocytes: 9.1
    Eosinophiles: 0.4
    Basophiles: 0.7
    Band: 0
    Laboratorios

    Troponin I
    – less than 0.12 ng/mL
    PT- 13.2 sec
    Pro-BNP - 64.8 pg/mL
    INR- 1.12 sec
    PTT- 25.2 sec
    EKG
    Diagnosis
    Primary Diagnosis Secondary Diagnosis Differential Diagnosis

    Obstructive Uropathy Hydrocele Lymphoma


    Pleural Effusion Renal Cancer
    Atelectasis Bladder Cancer
    DM type 2 uncontrolled Prostate Cancer
    R+ Uretherolithiasis
    Congestive Heart Failure
    Admissions orders
    • 06/23/2021 7:00PM
    • Admit to West Medical Ward under care of Dr Jonathan Ortiz
    • Dx: Obstructive Uropathy
    • Condition: Of Care
    • Prognosis : Guarded
    • Diet: Diabetic Diet 1,800 kcal
    • Activity: Bed Rest bathroom priviledge
    • Vital signs every 6 hours and chart
    • IVF’s – 0.45% NSS to run @ 10 ml/hr
    Admissions orders
    • Medications:
    - Metoprolol Succinate 25 mg PO two times daily
    - Tamsolusin 0.4 mg 1 capsule PO at bedtime
    - Simvastatin 20 mg 1 tab daily at night
    - Lovenox 30 mg subcutaneous daily
    - Insulin R 7 units subcutaneous with each meal
    - Lantus 20 units subcutaneous at night
    - Lasix 40 mg IV daily

    - Suspend Plavix 75 mg for 72 hrs


    Admissions orders
    • Laboratories:
    • Hepatic Panel, Pro-BNP , CK-MB , Lipid Panel , U/A , Urine Culture
    • HbA1C , Albumin:Creatinine ratio , ESR
    • CEA , ESR , BTA
    Radiologic Orders
    • Chest X-ray
    • Whole Body Gallium Scan
    • Renal Sonogram
    • 2-D echocardiogram Doppler Color Flow
    • Lymph Node Biopsy
    Consults:
    • Consult with Dr Alayon , Consult with Dr Corica
    Gracias !!!

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