DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Kidney stone.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with no previous history of urolithiasis. Last week, he had acute onset of right abdominal discomfort. He was evaluated in urgent care. A CAT scan was obtained, which showed a 3.9 mm right mid calculus and a smaller millimeter-size stone in his right kidney. He had moderate obstruction. The patient subsequently went on to pass this stone and presents now for evaluation today. At present, the patient denies any pain in the back, flank, or abdomen. He has seen no blood in his urine. There is no family history of kidney stones that he is aware of. He is a nonsmoker. He is treated for cholesterol and hypertension issues. Urinary-wise, he feels he is doing well. His urination score is only 3. He is pleased with his urination. He has no history of urologic procedures or operations.
PAST MEDICAL HISTORY: Reviewed.
PAST SURGICAL HISTORY: Reviewed.
REVIEW OF SYSTEMS: Reviewed.
LABORATORY DATA: Urinalysis, scanned to chart.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is afebrile. Blood pressure 124/80, pulse 66, respirations 18, and weight 212 pounds.
GENERAL: The patient is a well-developed, well-nourished Hispanic male, in no apparent distress.
NECK: Supple without JVD, thyromegaly, no bruits noted.
LUNGS: Clear without rales or wheezes, no dyspnea.
HEART: Regular rate and rhythm without murmur, no leg edema noted.
ABDOMEN: Soft, nontender. Bowel sounds are active. No masses or megaly noted. No umbilical or inguinal hernias noted.
GENITOURINARY: No CVA tenderness. Bladder is not palpable. Normal developed phallus without masses, tenderness, or lesions. Meatus is adequate without discharge. Both testes are present in the scrotum without masses or tenderness. Scrotum is without rashes or lesions.
LYMPHATIC: No inguinal adenopathy.
EXTREMITIES: Grossly within normal limits. Reasonable range of motion seen in the upper and lower extremities.
NEUROLOGIC/PSYCHIATRIC: Grossly within normal limits, oriented x3, normal affect and speech.
IMPRESSION:
1. Ureteral calculus: Subsequent interval passage of stone. The patient is now asymptomatic.
2. Renal stone: Small millimeter size, nonobstructing stone in the right kidney.
3. Hydronephrosis: Suspect resolved at present.
4. Microscopic hematuria: Trace on current urinalysis, micro negative.
5. Benign prostatic hypertrophy: Minimal symptoms.
6. Hypertension: Under control.
PLAN:
1. Ureteral calculus: Long discussion was held with the patient. At this juncture, we see no evidence of any residual stones. We will send his stone for analysis. He needs to stay well hydrated, avoid excessive intake of dairy products, salt and caffeine. We will tentatively see him back on a p.r.n. basis. Certainly, if he were to have recurrent stone issues, he may need to see Nephrology as well.
2. Kidney stone: As above, millimeter stone is too small to do a preemptive lithotripsy. Dietary restrictions reviewed with the patient.
3. Hydronephrosis: Suspect resolved. Monitor for recurrence if the patient becomes re-symptomatic.
4. Microscopic hematuria: No intervention indicated.
5. Benign prostatic hypertrophy: No indication for Flomax. Once he is 50 he needs a yearly digital rectal exam and PSA by his PCP.
6. Hypertension: Management and monitoring per primary physician.
Thank you for this consult. We will see the patient back on a p.r.n. basis.
