Urology Case Study

INITIAL OFFICE EVALUATION

This 27-year-old woman has complaints of being overweight, recurrent kidney and bladder infections, and intermittent fungal infections in body crevices.  She has had UTIs since age 12 but none in the past 3 years.  Has had 27 urethral dilatations which apparently made her problems worse since she has had no UTIs since they were discontinued 3 years ago.  Recently she suffered from pain in her right side for about 1 year.  Urologic evaluation revealed a blockage in the right ureter, and this was “cleaned out” cystoscopically, at which time scar tissue was found.  Was told that her right ureter had not been functioning.  It is apparently open now, and the pain has disappeared.  However, she was told she has blisters in her bladder and was advised to decrease consumption of acid foods.  This evaluation was done 6 weeks ago.  At that time she had numerous blood tests including TFTs and ECG, which were all normal.  In high school she weighed only 85 pounds but was taking 6 Ex-Lax tablets per day to keep her weight down.  She does not use Ex-Lax any more.  Currently she complains of irritability and “nastiness” if she does not eat frequently.  She craves sweets and chocolate which “make her happy” and energetic.  She complains of recurrent edema around her neck and other parts of her body.  She complains of fungal infections in certain crevices like under the breasts and in the antecubital fossa, occurring intermittently.

MEDICATIONS

Birth control pills for 5 years.  Supplements are none.

PAST MEDICAL HISTORY

Unremarkable.

ALLERGIES

None known.

REVIEW OF SYSTEMS

Gets some sinus headaches, periodic diarrhea, and has had 2 vaginal yeast infections in her life.

FAMILY HISTORY

Unremarkable.

HABITS

Negative.  Diet balanced, with excessive snacking and excessive sugar.

EXAMINATION:

Height 5 feet 2 inches, 149 pounds.  Blood pressure 120/80, pulse 84 and regular.  Is moderately overweight.  HEENT, neck, heart, lungs, abdomen, pulses, extremities, gross neurologic, skin, Achilles reflexes all normal.  Breast examination and internal examination done elsewhere.

ASSESSMENTS

1. Moderate overweight.

2. History of recurrent urinary tract infections and scar tissue in right ureter.

3. History of laxative abuse.

4. Symptoms of probable reactive hypoglycemia.

5. Recurrent edema.

6. “Blisters” in bladder, apparently healing, by repeat cystoscopy.

PLAN

We will do basic healthy diet and use supplements on enclosed note to reduce her craving for sugar and help control her blood sugar.  Return in 6 weeks.

FOOTNOTE

Line 32 (Page 1).  Are was added for clarity.

Line 1 (Page 2).  Exam was expanded to Examination in the report.  Height was added to avoid beginning the sentence with a numeral.

Line 9 (Page 2).  Alternative:  Moderately overweight.

Line 10 (Page 2).  The dictated UTIs was translated in the assessment for clarity.