SOAP Note

Subjective:

The patient is a 38-year-old male presenting with abdominal pain, intermittent chills, perspiration, nausea, and vomiting. He also reports increased urinary frequency without hematuria.

Objective:

• CBC: WBC 14.1, seg neut absolute 11.9
• CMP: Glucose 149, Chloride 110, ALT-SGPT 59
• Urinalysis: Trace of blood, trace of protein, moderate squamous epithelial cells
• CT Abdomen: Left-sided hydronephrosis and hydroureter secondary to a 2 mm calculus at the UVJ, bilateral nephrolithiasis

Assessment:

The patient's symptoms and diagnostic findings suggest a urinary tract issue, potentially related to the presence of kidney stones.

Plan:

Given the patient's presentation and diagnostic findings, the differential diagnosis can be organized as follows:

• Single Most Likely Diagnosis
  • Nephrolithiasis with Obstruction: The patient's symptoms of abdominal pain, nausea, vomiting, and increased urinary frequency, combined with the CT findings of a 2 mm calculus at the UVJ causing hydronephrosis and hydroureter, make this the most likely diagnosis. The presence of bilateral nephrolithiasis further supports this diagnosis.
• Other Likely Diagnoses
  • Urinary Tract Infection (UTI): Although the patient does not report hematuria, the trace of blood and protein in the urine, along with the presence of moderate squamous epithelial cells, could suggest a UTI. The elevated WBC count also supports this possibility.
  • Pyelonephritis: The patient's symptoms of chills, perspiration, and abdominal pain, along with the elevated WBC count and the presence of a urinary tract obstruction, could indicate pyelonephritis, especially if the obstruction is causing an infection.
• Do Not Miss Diagnoses
  • Sepsis: Although less likely given the patient's current presentation and the fact that the nausea has improved with Zofran, sepsis is a potentially life-threatening condition that must be considered, especially if the patient's condition worsens or if there are signs of systemic infection.
  • Appendicitis: Although the pain has migrated anteriorly and the CT suggests a urinary issue, appendicitis can sometimes present with atypical symptoms and must be considered, especially if the patient's pain pattern or other symptoms suggest an abdominal emergency.
• Rare Diagnoses
  • Renal Cell Carcinoma: While rare, a tumor could potentially cause obstruction and the patient's symptoms. However, this would be less likely given the acute presentation and the presence of a clear obstructing calculus on CT.
  • Other Rare Causes of Obstruction: Other rare causes, such as blood clots or sloughed papillae, could also cause obstruction but are less likely given the clear evidence of nephrolithiasis.

Plan:

The patient should be managed with pain control, hydration, and potentially medical expulsive therapy for the stone. Antibiotics may be considered if there is a high suspicion of infection. Close monitoring of the patient's condition and renal function is necessary. If the stone does not pass, urological intervention may be required.