MD12-0008 Calaguas, Noriel P.

CLINEX Group 5

Surgery Clinex Write-up

Patient: Jigger O. Carmen (JOC)
Date of Birth: December 2, 1975
Date of Interview: July 18, 2014
Place of Interview: TMC-Surgery OPD
Informant: Patient himself and wife (Josephine)
Reliability: Very Good
Attending Physician: Dr. Norman Bustos
GENERAL INFORMATION
JOC is a 38-year-old married Roman Catholic Filipino residing in Tipas,
Taguig City.
CHIEF COMPLAINT
JOC complains of burning right flank pain, experienced every morning for
the past month.
HISTORY OF PRESENT ILLNESS
Ten years prior to consult (PTC) patient underwent right kidney
pelviolithiotomy at the Philippine General Hospital to remove calcium stones.
One year prior PTC, patient reports first experiencing a 5/10 right flank
pain, occasionally radiates to the epigastric area, pain is frequently worse in the
morning. The patient runs for about an hour to relieve the pain, after which he
drinks about a liter of water and reports gross hematuria. Patient reports to
experience this pain about one to three times a week. Patient denies anuria,
dysuria, polyuria, or hesitancy.
Ten months PTC, patient underwent KUB sonogram that revealed bilateral
nephrolithiasis, with the largest stone in the right kidney measuring 9.99x4.94mm
and the largest stone in the left kidney measuring 10.3x5.37mm.
Two months PTC, the frequency of the pain was experience almost on a
daily basis and amount of blood in the urine has increased. Patient describes the
flank pain as an escalating, burning pain, which would last for about 15 minutes
after which he would initiate his relieving activity (running).
One month PTC, patient underwent a second KUB sonogram this time
revealing right unilateral nephrolithiasis. The sonologist reports findings of three
stones measuring 0.9cm, 1.01cm, and 0.25cm.
Patient presents on consult with a burning right flank pain of a 5/10 pain
scale.

MD12-0008 Calaguas, Noriel P.

CLINEX Group 5

TEMPORAL PROFILE

REVIEW OF SYSTEMS
General: (-) Weight gain/loss, (-) weakness, (-) fever, (-) fatigue
MSK/Integumentary: (-) rashes, (-) lumps, (-) sores, (-) itching, (-) changes in color,
(-) muscle pain, (-) joint pain
HEENT: (-) headache (-) dizziness, (-) tinnitus, (-) deafness, (-) frequent colds, (-)
epistaxis, (-) hoarseness, (-) dry mouth, (-) gum bleeding, (+) blurring of vision, (-)
enlarged LN
Respiratory: (-) dyspnea, (-) cough, (-) hemoptysis, (-) wheezing
Cardiovascular: (-) palpitations, (-) syncope, (-) orthopnea, (-) chest pain
GI: (-) nausea, (-) vomiting, (-) dysphagia, (-) heartburn, (-) diarrhea (-)
constipation, (-) jaundice, (-) rectal bleeding
Endocrine: (-)cold/hett intolerance, (-) polyuria, (-) excessive thirst, (-) excessive
sweating
GU: (-) dysuria, (-) discharge, (-) sexual dysfunction
Neurologic: (-) seizures, (-) tremors
PAST MEDICAL HISTORY
JOC doesnt recall when he was hospitalized for Typhoid fever. The patient
was given IV medications (cannot recall the drug name). No other reasons for
hospitalization were reported.
FAMILY HISTORY
JOC is an only son and denies
any hereditary disease in his family,
but reports a maternal uncle that was
diagnosed and treated for
Nephrolithiasis. JOC has 2 offspring
with his wife. And they live together
with his wifes two nieces and a
nephew

MD12-0008 Calaguas, Noriel P.

CLINEX Group 5

REPRODUCTIVE HISTORY
Patient reports that he only has one sexual partner, his wife and cannot
recall age of first coitus. Denies having any sexually transmitted infection.
IMMUNIZATION HISTORY
JOC recalls that he received vaccinations as a child but cannot recall
specific vaccines. He reports that he hasnt received any of the recommended
adult vaccinations.
PERSONAL/SOCIAL HISTORY
JOC is a college graduate with a degree in electrical technology, but currently
works as a waiter. He was very fond of drinking milk years prior to his first diagnosis
of nephrolithiasis. He was a heavy alcoholic beverage drinker prior to his surgery in
2004, post-operatively he occasionally drinks, and cumulatively he has 16 pack-years.
He has taken methamphetamine for quite sometime prior to his pelviolithotomy.

SOCIAL and ENVIRONMENTAL HISTORY

JOC lives a concrete bungalow; they are supplied with electricity and have
a refigirator, and a few kitchen appliances. They get their drinking water from a
filtered tap. Garbage is collected twice a week. No history of pertinent travel
STAKEHOLDERS ANALYSIS
JOC is the sole breadwinner of the family, and his wife is a full time
housekeeper. JOC currently makes contributions to both his PhilHealth and SSS
membership. JOC consults with his wife about matters concerning his health and
decide as one unit. In times of hospitalizations, they call on one of his wifes
nieces to take care of their 2 children and 2 other nieces.
PHYSICAL EXAMINATION
General Description: Conscious and alert, responds well to
Anthropometrics
Ht: 56
Wt: 60kg
Vital Signs
HR: 66 bpm
RR: 15 bpm
T: 36.1C
BP: 120/100 mmHg
Head and Neck
Hair and Scalp: A head full of black, thin and course hair, no alopecia, and
absence of parasites as well
Head: No gross deformities were noted.
Ears: On external exam, both ears are symmetrical.
Nose: No septal deviation, scars, lesions or masses (external examination)
Throat: pink oral mucosa, no ulcerations, with no tonsillar hypertrophy,
non-hyperemic posterior pharyngeal wall, and central located uvula, not
missing any teeth.
Neck: Neck is symmetrical with full range of motion. No lymphadenopathy,
trachea is midline.

MD12-0008 Calaguas, Noriel P.

CLINEX Group 5

Eyes
Inspection: Pink palpebral conjunctivae, anicteric sclerae. Pupils are
aligned and equally reactive to light accommodation. No matting of
eyelashes.
Chest: Cardiovascular
Inspection: Adynamic precordium, no pectus carinatum or excavatum. No
visible pulsations, no precordial bulge.
Palpation: palpable beats at the 2nd left parasternal border; PMI at the 5th
left ICS MCL.
Auscultation: Regular rate and rhythm, no murmurs, S2 louder at base and
S1 louder at apex. No aortic or carotid bruits. grade 2/6 systolic murmurs at
the 5th ICS MCL.
Chest: Pulmonary
Inspection: Symmetrical chest expansion, no intercostal retractions or use
of accessory muscles when breathing, no alar flaring.
Percussion: Resonant on all lung fields
Palpation: Equal tactile fremiti on all lung fields and equal thoracic
expansion upon inspiration.
Auscultation: No adventitious breath sounds;
Abdomen
Inspection: Abdomen was flat. There were no visible herniations and other
gross deformities. Present scar on right flank from prior lumbotomy.
Auscultation: Normoactive bowel sounds.
Percussion: Tympanitic on all 4 quadrants, no hepatomegaly
Palpation: No tenderness on light and deep palpation on all quadrants
Back and Spine
Inspection: Back was symmetric, no kyphosis or lordosis, no deformities
were noted
Palpation: (+) Costovertebral Tenderness
Pelvis and GU Tract
Inspection: Not assessed
Palpation: Not assessed
Upper and Lower Extremities
Inspection: Short fingers with rounded tips, No clubbing, no bipedal
edema, and capillary refill time <2 sec.
Integumentary
Skin: Dry and warm to touch, no cyanosis noted.
Nails: Smooth, trimmed, consistent in color, clean and dry finger and
toenails with no deformities, No clubbings.
DIFFERENTIAL DIAGNOSIS
Diagnosis
Rule In
Nephrolithiasis
(+) Burning Right
Flank Pain

Rule Out

Work Up
Urinalysis
CBC

MD12-0008 Calaguas, Noriel P.

(+) Costovertebral
Tenderness
(+) Intermittent
Hematuria
Pyonephiritis
(+) Burning Right
Flank Pain
(+) Costovertebral
Tenderness
(+) Intermittent
Hematuria
Acute
(+) Burning Right
Glomerulonephritis Flank Pain
(+) Costovertebral
Tenderness
Urinary Tract
Infection

(+) Burning Right

Flank Pain
(+) Costovertebral
tenderness
(+) Intermittent
Hematuria

CLINEX Group 5
Chemistries
KUB
BUN/Crea
(-) Fever
(-) Dysuria
(-) Pyuria

Urinalysis
BUN/Crea
GS/C&S
Blood and Urine
Culture

(-) Periorbital
Edema
(-) Elevated JVP
(-) Altered Level of
Consciousness
(-) hx of UTI
(-) penile meatal
discharge
(-) fever
(-) abdominal
tenderness
(suprapubic area)

Urinalysis
CBC
Blood and Tissue
Culture
Streptozyme test
Urinalysis
Urine GS/C&S

PRIMARY WORKING IMPRESSION: Nephrolithiasis

The colicky-type pain known as renal colic usually begins in the

upper lateral midback over the costovertebral angle and occasionally
subcostally. It radiates inferiorly and anteriorly toward the groin. The pain
generated by renal colic is primarily caused by the dilation, stretching, and
spasm caused by the acute ureteral obstruction. (When a severe but
chronic obstruction develops, as in some types of cancer, it is usually
painless.)
In the ureter, an increase in proximal peristalsis through activation of
intrinsic ureteral pacemakers may contribute to the perception of pain.
Muscle spasm, increased proximal peristalsis, local inflammation, irritation,
and edema at the site of obstruction may contribute to the development of
pain through chemoreceptor activation and stretching of submucosal free
nerve endings.
The hematuria could be due to the physical activity (i.e. running as a
relieving activity) dislodging and traumatizing surrounding structure if the
stones, which leads to gross hematuria.
The laboratory diagnostics would confirm that they are indeed
kidneys and might disclose the composition of the stones through

MD12-0008 Calaguas, Noriel P.

CLINEX Group 5

anomalies in serum electrolytes. BUN/Crea will ascertain kidneys functional

level.
MANAGEMENT:
SURGICAL
Extracorporeal Shockwave Lithotripsy with Stenting
NON-PHARMACOLOGIC
Refer to Ophthalmologist for blurring of vision
PREVENTION
Remind client about proper hydration principles
References:
1. Longo, Fauci, et al (2011). Nephrolithiasis. Harrisons Principles of
Internal Medicine: Chapter 287 Nephrolithiasis. 18th ed.