INITIAL OFFICE EVALUATION
HISTORY
Patient
is a 49-year-old white female that presents with a history of having acute
onset of right flank pain x12 hours.
Patient awoke this morning with sharp stabbing pain that started at
right midback and radiated to the right lower quadrant. There was no nausea, fevers, chills,
diarrhea, constipation, rectal bleeding, dysuria, or hematuria. Pain resolved about an hour before she got
here.
Examination
of the back indicates no focal tenderness or spasm. Abdomen indicates minimal discomfort in the
right lower quadrant, otherwise unremarkable.
Pelvic: Blind vaginal pouch. No pain.
Rectal exam: Stool heme negative.
Patient
has had a cholecystectomy and a partial hysterectomy with an appendectomy.
Urinalysis
showed hematuria greater than 100 red cells, 0 to 1 white cells, occasional
bacteria. White cell count was elevated,
14,700. Amylase 57, SGOT 33. X-ray unremarkable.
OVERALL IMPRESSION
Hematuria,
probably due to the passage of a renal stone, now asymptomatic.
PLAN
Ampicillin
for prophylactic coverage of potential infection,
500 mg q.i.d. IVP to be ordered and to be followed up by her physician.
500 mg q.i.d. IVP to be ordered and to be followed up by her physician.
FOOTNOTE
Line
8. Alternative to that: Who.
Line
11. Alternative: Mid back.
Line
24. Alternative: 0-1.
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