CHART NOTE
HISTORY
The
patient presented to my office yesterday.
A urinalysis revealed 3+ blood in his urine. The patient had a great deal of abdominal
pain last night, but this had resolved upon presentation to the office. There was no pain over McBurney point.
LABORATORY STUDIES
His
SMA-20 is normal except the LDH is 48, a normal level being
9 to 42. His glucose is 122. His cholesterol is 178. Today,
x-ray examination revealed a small radiopaque calculus lodged in the distal right ureter, causing mild proximal hydronephrosis and hydroureter. A KUB did not reveal this calculus. His white count was 13,000 with 83 segmented neutrophils and 8 band neutrophils.
9 to 42. His glucose is 122. His cholesterol is 178. Today,
x-ray examination revealed a small radiopaque calculus lodged in the distal right ureter, causing mild proximal hydronephrosis and hydroureter. A KUB did not reveal this calculus. His white count was 13,000 with 83 segmented neutrophils and 8 band neutrophils.
DIAGNOSIS
Nephrolithiasis.
FOLLOWUP
Patient
was instructed to continue drinking large amounts of fluids and to take Septra
DS 1 b.i.d. He was instructed to strain
all urine and to save any stones or even particles resembling a grain of
sand. The patient will follow up with me
in the office on Tuesday afternoon, but he may return to work tomorrow if he so
desires.
FOOTNOTE
Line
16. Alternative: 9-42.
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