Urology

DISCHARGE SUMMARY

DISCHARGE DIAGNOSES

1. Left hydronephrosis.

2. Possible left ureteral obstruction.

3. Rule out horseshoe kidneys.

BRIEF HISTORY

A 61-year-old male who developed flank pain on the left side.  He has had intermittent episodes of left flank pain which have lasted about 24 hours.  There is no history of hematuria or renal calculi.  He developed a similar episode earlier this week which persisted for 72 hours, and repeat IVP demonstrated progression of the hydronephrosis on the left side.  He denied fevers, chills, or history of urinary tract infections.  He does have mild BPH as well, with some decrease in force of stream.

His past history is essentially negative other than a history of esophagitis.  He is on no medications.  Denied allergies or previous surgeries.

Physical examination was significant for grade 2/4 left flank and left lower abdominal tenderness.  Otherwise, physical examination was within normal limits.

HOSPITAL COURSE

The patient was admitted for pain control.  Serum creatinine was 1.7.  On the second hospital day, he underwent cystoscopy and left retrograde pyelogram which revealed a possible left ureteral stricture.  This was dilated.  There were no stones apparent, and a double-J stent was left in place.  Postoperatively the patient was pain-free.  Stent will be removed in about 1 month’s time.  His medications on discharge include Septra DS 1 b.i.d. and Vicodin.

FOOTNOTE

Line 15.  Are was changed to is for subject-verb agreement
(is ... history...).