DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left ureteral calculus.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old African-American female was seen in urologic consultation at the request of Dr. John Doe because of presence of a left ureteral stone. The patient was admitted to the emergency department and then to the hospital because of the pain in the left flank area. The pain began yesterday and was intermittent but then became more severe during the night, therefore she came to the ED. Unfortunately, they did a CAT scan with contrast. It did show that she does have a calculus in the left ureter, around L3-L4. Therefore, because of the contrast, we were unable to do an IVP. She does have a mild hydronephrosis. She has no previous history of any calculus disease.
PAST MEDICAL HISTORY: Essential negative for TB, diabetes or carcinoma.
PAST SURGICAL HISTORY: A total hysterectomy and a thyroidectomy.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: The patient’s brother had tuberculosis. The patient did not live with him at the time. She has no history of cancer, diabetes or serious medical illnesses in her family.
REVIEW OF SYSTEMS: The patient is very healthy. She denies any history of cardiovascular, respiratory or gastrointestinal problems. No evidence of any urinary tract calculi, and she has no history of recurrent urinary tract infections.
PHYSICAL EXAMINATION:
GENERAL: A well-developed, well-nourished African-American female with pain in the left flank area and left costovertebral angle area.
HEENT: Eyes, ears, and throat were negative.
NECK: Supple, no masses.
HEART: Revealed a regular rate and rhythm with no murmurs.
LUNGS: Clear. No rales, wheezes or rhonchi.
ABDOMEN: Examination of the abdomen revealed scar in the suprapubic area. She was tender in the left costovertebral angle area, as well as just lateral to the umbilicus on the left.
GENITALIA: Not examined at this time.
DIAGNOSTIC STUDIES: We did review the CAT scan. It does show the presence of a 3 to 4 mm calculus in the left ureter around the level between L3 and L4 with mild hydronephrosis. As mentioned above, they did give the patient oral contrast, therefore an IVP cannot be done.
IMPRESSION: Mid left ureteral calculus, which is difficult to see on the KUB.
RECOMMENDATION: Renal flow study to ascertain whether or not the patient has a total obstruction or whether the kidney is functioning. If the obstruction is severe, then cystoscopic examination with insertion of a double-J stent may be necessary. If the patient has an incomplete obstruction and the kidney is functioning, we can treat her conservatively with antispasmodics, pain medication and antibiotics and hope that she will pass the calculus spontaneously.
