Kidney Stone ER Sample Report #1
CHIEF COMPLAINT: Kidney stone.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was seen last night in the emergency department with a kidney stone. He has a 2 mm stone at the right UPJ, with moderate hydronephrosis. He saw Urology today. He states that he was changed from Lortab to Percocet. He states that he has had increased pain in the right side of his abdomen. It is intermittent and sharp, currently 8/10 in intensity. He did take Percocet several hours ago without improvement in his symptoms. No nausea, vomiting or diarrhea.
PAST MEDICAL HISTORY:
1. Significant for gout.
2. Kidney stones.
SOCIAL HISTORY: Unremarkable.
ALLERGIES: None.
PHYSICAL EXAMINATION:
VITAL SIGNS: BP 110/66, temperature 97.8, pulse 70, respirations 18.
GENERAL: A well-developed (XX)-year-old. Appears a little uncomfortable, otherwise in no distress.
HEENT: Moist mucous membranes.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
RESPIRATORY: Lungs clear to auscultation bilaterally.
GASTROINTESTINAL: The patient’s abdomen is soft. Positive bowel sounds. Slight tenderness in the right lower quadrant.
MUSCULOSKELETAL: Slight tenderness, right CVA region.
ANCILLARY SERVICES: KUB of the abdomen shows no evidence of renal calculi.
EMERGENCY DEPARTMENT COURSE: He was seen and examined. He was given IV fluids as well as Dilaudid, Toradol, and Phenergan. His old charts were reviewed. He did have a CT with a 2 mm stone at the right UPJ last night. There is a normal appendix seen. The patient was re-examined. He was pain-free, and he was discharged in good condition.
MEDICAL DECISION MAKING: A (XX)-year-old male with renal calculi. We will discharge him to home. He is to push clear liquids. Strain urine. Dilaudid 2 mg, #15. Toradol 10 mg, #12. Follow up with Urology. Return if worsened symptoms.
DISPOSITION: Home.
DIAGNOSIS: Acute right renal calculi.
Kidney Stone ER Sample Report #2
CHIEF COMPLAINT: Kidney stone.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female states that for the last 2 to 3 days she has had a history of left flank pain. She states at 3 a.m. yesterday morning it became worse. It is present in her left flank and is nonradiating. She has had stents in both ureters. She states that her urine has been dark. Her pain has been constant, sharp, 9/10 in intensity, nonradiating. She has taken Percocet without any improvement. She is now out of it.
PAST MEDICAL HISTORY:
1. Renal calculi.
2. Tubal ligation with reversal.
3. Nephrostomy tube.
SOCIAL HISTORY: Unremarkable.
ALLERGIES: Vicodin.
PHYSICAL EXAMINATION:
VITAL SIGNS: BP 150/106, temperature 98.4, pulse 108, respirations 16.
GENERAL: A well-developed (XX)-year-old in no distress, appears uncomfortable.
HEENT: Moist mucous membranes.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
RESPIRATORY: Lungs clear to auscultation bilaterally.
GASTROINTESTINAL: The patient’s abdomen is soft. Positive bowel sounds. Slight tenderness in the left lower quadrant.
MUSCULOSKELETAL: She is tender with percussion in the left CVA region.
ANCILLARY SERVICES: CT abdomen, stone protocol, shows bilateral stents. There is hydronephrosis. It is essentially unchanged from March according to the radiologist. Pregnancy test negative. Urinalysis shows 50-100 wbc’s, positive nitrite, many bacteria. CBC is normal.
EMERGENCY DEPARTMENT COURSE: She was seen and examined. She underwent workup. She was given IV fluids as well as Dilaudid, Phenergan and Toradol. Upon re-examination, she was feeling better, but her pain was still 4/10 in intensity. She was given another dose of Dilaudid and she was given a dose of p.o. Cipro. She was discharged in good condition.
MEDICAL DECISION MAKING: A (XX)-year-old female with renal colic and UTI. We will discharge her to home. Cipro 500 mg, #10, Percocet 7.5 mg, #12. She is to push clear liquids. Follow up with Urology tomorrow and return if worsened symptoms.
DISPOSITION: Home.
DIAGNOSES:
1. Acute urinary tract infection.
2. Acute renal colic.
Kidney Stone ER Sample Report #3
CHIEF COMPLAINT: Kidney stone.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Caucasian male with a history of kidney stones who presents to the emergency department complaining of left lower quadrant pain, left flank pain, that radiates to left lower quadrant since last night. The patient states he thinks it may be kidney stones. He has had kidney stones in the past, approximately 5 years ago, and does feel somewhat similar. He has had nausea but denies any vomiting or diarrhea. Denies any dizziness, lightheadedness, headache, blurred vision, neck pain or stiffness, fever or chills, shortness of breath, chest pain, palpitations or cough. Denies any dysuria, hematuria, frequency, urgency, bowel or bladder incontinence. Denies any back pain or paresthesias, melena or dark tarry stools.
PAST MEDICAL HISTORY:
1. Knee surgery.
2. Back surgery.
3. Asthma.
4. Kidney stones.
CURRENT MEDICATIONS: Proventil.
ALLERGIES: CODEINE.
SOCIAL HISTORY: Occasional alcohol use. Denies any tobacco or illicit drug use.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As above, otherwise negative per patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/86, pulse 86, respirations 20, temperature 98.8, and O2 saturation on room air is 98%.
GENERAL: The patient is alert and oriented x3, no acute distress, nontoxic in appearance, is ambulatory in the emergency department.
SKIN: Warm and dry to touch.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Positive bowel sounds, all 4 quadrants. The patient does have left lower quadrant tenderness but no rebound, no guarding. No organomegaly or masses noted.
BACK: Negative CVA tenderness.
EXTREMITIES: The patient has 2+ pulses in all extremities. No ecchymosis, edema, erythema or deformity noted.
EMERGENCY DEPARTMENT COURSE: CBC, renal, urinalysis, CT scan of the abdomen and pelvis without contrast were all ordered. The patient did receive a liter of normal saline, wide open, Toradol 30 mg IV for pain. He did not want anything for nausea.
LABORATORY RESULTS: CBC: White count 19.3, hemoglobin 16.4, hematocrit 47.8, platelets are 282. Renal: Sodium 138, potassium 4.8, chloride 103, bicarbonate 24, BUN is 11, creatinine is 1.0, glucose is 113, anion gap is 11, calcium is 10.1. Urinalysis showed 15 ketones but otherwise negative.
CT SCAN: CT scan of the abdomen and pelvis did show positive lower descending diverticulitis, no abscess, no hydronephrosis or stone. Positive cholelithiasis.
IMPRESSION: This is a (XX)-year-old male with left lower quadrant pain with white count of 19,000 with diverticulitis on CT scan. He was started on Cipro 400 mg IV and Flagyl 500 mg IV here in the emergency department. At this point, we spoke to Dr. John Doe. The patient is adamant about going home. He does not want to be admitted to the hospital. Dr. John Doe is okay with the patient being discharged home with close followup with Dr. John Doe next week.
DIAGNOSIS: Diverticulitis.
PLAN:
1. The patient was given Vicodin 1, four to six hours p.r.n. pain, #20.
2. Cipro 500 b.i.d. x7 days and Flagyl 500 t.i.d. x 7 days.
3. He is to follow up with Dr. John Doe on Monday at 10:30. He is to call for an appointment.
4. Decrease greasy foods.
5. Liquid diet x2 days, then as tolerated. No greasy fatty foods.
6. If fevers, vomiting, increased pain or worse, the patient can return to the emergency department.
DISPOSITION: The patient was discharged in stable condition.
