DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left hydronephrosis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who was admitted with worsening fatigue. The patient has a history of decreased ejection fraction, congestive heart failure, pulmonary hypertension, diabetes, atrial fibrillation, and hyperlipidemia. He has also been on Coumadin in the past. During this hospitalization, the patient was admitted for Coumadin reversal and cardiac catheterization. The patient is reported to have severe mitral stenosis and moderate aortic stenosis with an ejection fraction of 30%. During this time, he has also had a history of chronic renal insufficiency, and his creatinine has fluctuated between 1.5 and 2.0. The creatinine at the time of admission was 1.7 and was high as 2.0 yesterday. This has decreased to 1.5 today. The patient had a renal ultrasound revealing left hydronephrosis and left hydroureter. The patient denies any left flank pain. The patient gives a history of BPH with a history of occasional nocturia of one to two times per night and some urinary frequency. He has been on Uroxatral for approximately five months. The patient denies any prior urinary tract infection or hematuria. He states that he has seen Dr. Jane Doe in the past, who had recommended a transurethral resection of the prostate. The patient did not wish to have this done and has not followed up with her.
PAST MEDICAL HISTORY: As noted above.
PAST SURGICAL HISTORY: Cardiac catheterizations.
CURRENT MEDICATIONS: Heparin drip, isosorbide mononitrate, Protonix, aspirin, Lipitor, Uroxatral 10 mg daily, Coreg, glipizide, digoxin, hydralazine, insulin, and isosorbide dinitrate.
ALLERGIES: The patient denies any drug allergies.
SOCIAL HISTORY: The patient has a 35-year smoking history but has quit in the remote past.
REVIEW OF SYSTEMS: As noted above. The patient states that he has dyspnea, but he is able to walk halfway down the hallway on the hospital floor. He denies any prior history of stones. He has no flank pain on the left side or nausea or vomiting.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert, in no obvious respiratory distress.
NECK: Supple.
LUNGS: Respirations are unlabored.
HEART: Regular with no obvious fibrillation.
ABDOMEN: Flat. He has no inguinal hernias. He has a catheterization dressing in his right groin.
RECTAL: Examination reveals a normal sphincter tone with a flat, small prostate. There were no obvious prostate nodules. There is no obvious bulky BPH.
EXTREMITIES: The patient has no lower extremity pitting edema.
IMPRESSION:
1. Left hydronephrosis and hydroureter.
2. History of benign prostatic hypertrophy, on Uroxatral.
3. Severe cardiac valvular disease, congestive heart failure, and atrial fibrillation, requiring Coumadin.
PLAN: We will order a MAG-3 renal scan to rule out obstruction. We will also start with a KUB to rule out stones given that the patient has minimal symptoms. Should the renal scan be negative and the KUB negative, the patient may need a noncontrast CT scan to rule out asymptomatic obstructing left ureteral stone. The patient is scheduled for surgery on Thursday, and we will attempt to expedite this. The patient is not a candidate for a preoperative ureteral stent due to his cardiac disease and would not benefit from a nephrostomy tube due to his need for immediate and chronic anticoagulation. We will likely follow his creatinine given that he is near his baseline and is fluctuating between 1.5 and 2.0.
