DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hematuria.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who started having blood in the urine four days ago. She took two antibiotics without improvement. Associated symptoms are right flank pain as well as dysuria, urinary frequency and urgency. The patient was admitted because of hemoglobin of 8.4. She was also noted to be in renal failure with a creatinine of 5.8. CT scan showed a stone in the left kidney without obstruction. No obstruction on either side noted or metastatic disease noted. The patient has a history of metastatic colon cancer.
PAST MEDICAL HISTORY: Metastatic colon cancer, status post left colectomy and chemotherapy with apparently 5-FU.
MEDICATIONS ON ADMISSION: Darvocet, Ziac, Soma, and lisinopril.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse.
ALLERGIES: PENICILLIN.
REVIEW OF SYSTEMS: Positive for some malaise. No fever or chills. No headaches or seizures. No visual changes or eye pain. No hearing problems or earaches. No chest pain or palpitations. No shortness of breath or wheezing. No nausea, vomiting or abdominal pain. For GU, see above. The patient denies any backaches or arthralgia. No bleeding tendency but a history of anemia. No allergies or frequent infections. No anxiety or depression. No diabetes or thyroid disease.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is afebrile. Heart rate, respirations, and blood pressure all well controlled.
GENERAL: The patient is in no apparent distress, although she appears slightly somnolent.
HEAD AND NECK: Exam showed that she is normocephalic and atraumatic. Neck is supple. Trachea is in midline. No JVD noted.
LUNGS: Respirations unlabored. No audible wheezing or rhonchi.
ABDOMEN: Soft, nondistended, nontender. Scars from previous surgeries. Bladder is not palpable.
EXTREMITIES: Show full range of motion x4.
NEUROLOGIC: No focal neurological deficits noticed.
SKIN: Warm, dry, and appears to be intact.
LABORATORY DATA: Results are reviewed. CBC shows a WBC of 15.6, hemoglobin 8.4, hematocrit 25.4, and platelet count 384,000. Differential shows 81.6% neutrophils. Chemistry shows normal electrolytes. BUN 74, creatinine 5.8. Liver function is elevated. Urinalysis showed specific gravity of 1.020, pH 7.5, 2+ albumin, 1+ glucose, 1+ ketones, 2+ bilirubin, 3+ occult blood, positive nitrites, positive urobilinogen, 1+ leukocyte esterase. Microscopic shows more than 50 rbc’s per high power field, 5 to 10 wbc’s per high power field, and 1+ bacteria.
DIAGNOSTIC DATA: CT scan shows left kidney stones without obstruction. No obstruction or other stones noted. Metastatic disease and lymphadenopathy noted.
IMPRESSION AND RECOMMENDATIONS: Probable urinary tract infection with hematuria and left kidney stone, which is nonobstructing. Renal failure, possibly due to dehydration. The patient currently refuses Foley catheter. The patient is voiding spontaneously and states that she is emptying the bladder well. The CT scan shows what appears to be a clot in the bladder. Recommend antibiotic coverage. Monitor blood levels. Hydrate and continue antibiotic therapy.
