CHIEF COMPLAINT: Blood in urine.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad for evaluation. The patient was seen on MM/DD/YYYY after an assault. He was noted to have hematuria. He had an initial trauma CT, which was normal. He was admitted to Mental Health at that time as he was suicidal. The patient continued to have hematuria. Apparently, a repeat CT was done, which showed a wedge-shaped area of high density in the right kidney. An ultrasound of the retroperitoneum was done yesterday, which was negative. The patient was discharged home. The patient states that he did pass some clots. He had some similar symptoms last night as well. He has not seen Neurology. No fever or chills. He has had some dysuria. He has had some right flank pain as well. The patient states his pain is 8/10 in intensity. No treatment prior to arrival.
PAST MEDICAL HISTORY:
1. Polysubstance abuse.
2. Chronic pain.
3. Depression.
SOCIAL HISTORY: The patient is a smoker.
ALLERGIES: None.
PHYSICAL EXAMINATION:
VITAL SIGNS: BP 146/94, temperature 98.2, pulse 72, respirations 18.
GENERAL: A well-developed (XX)-year-old who appears uncomfortable. Otherwise, no distress.
HEENT: Moist mucous membranes. Sclerae nonicteric.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. Positive bowel sounds. Slight tenderness suprapubically.
MUSCULOSKELETAL: He has slight tenderness with percussion in the right CVA region.
LABORATORY AND RADIOLOGY DATA: CBC is normal. Chem-7 normal. Urinalysis shows too numerous to count rbc’s, 5-10 wbc’s, 3-5 squamous epithelial cells. CT of the abdomen normal, as read by the radiologist.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. He underwent workup. He was given IV fluids. He was also given a dose of morphine. A Foley catheter was placed, which demonstrated gross hematuria. The catheter was irrigated. There were no clots. This was irrigated until clear.
We did discuss the patient with Dr. John Doe, who was covering for Urology. Arrangements have been made for the patient to follow up with them in the morning at their urology center. The patient was informed of this, and he was discharged in good condition.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with hematuria. He has had a stable hemoglobin when compared with recent records. His blood pressure has remained stable. He has had a recent retroperitoneal ultrasound yesterday, which was normal. He will be discharged home. He is to follow up with Urology in the morning.
PLAN:
1. Percocet #10.
2. Push clear liquids.
3. Return for worsening symptoms.
DISPOSITION: Home.
DIAGNOSIS: Acute hematuria.
