Urology Study

HISTORY AND PHYSICAL EXAMINATION

HISTORY

This 38-year-old male was admitted through the emergency room with a history of less than 1 day of acute ureteral colic on the left side.  Patient had an IVP in the emergency room earlier today, which shows partial to complete obstruction of the left ureter at the ureterovesical junction with a large stone approximately 8 x 5 mm lodged at the UV junction.  Patient has no other calcifications visible.  Patient denies any previous history of urinary tract stones or other GU problems except for prostatitis a couple of years ago.  Patient has no other significant medical problems.

PAST MEDICAL HISTORY

Otherwise negative.

ALLERGIES

None.

MEDICATIONS

None.  Follows usual diet.

FAMILY HISTORY

No familial history of kidney stones or other significant hereditary disease.

PHYSICAL EXAMINATION

GENERAL:  Physical examination reveals a well-nourished,
well-developed male in no acute distress.

HEENT:  Pupils equal, round, react to light.  Ears, nose, and throat clear.

NECK:  Neck supple.  No JV distention or bruit.

LUNGS:  Lungs clear to P&A.

HEART:  Regular rhythm, no murmur.

ABDOMEN:  Abdomen soft.  Slight left CVA tenderness, slight left lower quadrant tenderness.  No rebound.

GENITALIA:  Genitalia within normal limits.  Penis reveals normal male.

EXTREMITIES:  No cyanosis, clubbing, or edema.

NEUROLOGIC:  Neurologically oriented x3 with no gross deficits.

IMPRESSION

Left lower ureteral stone with obstruction.

RECOMMENDATION

Hydration, analgesia, observation, and if stone does not pass within 72 hours or less, we will probably recommend patient for ureteroscopy and stone basketing and, if needed, ultrasonic lithotripsy.  If the stone cannot be mobilized downward,
push-back and ESWL (extracorporeal shock wave lithotripsy) might be considered.

FOOTNOTE

Line 28 (Page 1).  The heading Family History was added.

Line 32 (Page 1).  Exam was expanded to Examination in the report.

Lines 33-45 (Page 1).  Subheadings were added in the Physical Examination.

Line 5 (Page 2).  ESWL was translated for clarity.