Chapter 12: The Urinary System | Brian Simmons's Chart Note

CHART NOTE

Patient Name: Simmons, Brian
ID Number: 53589
Examination Date: March 13, 20xx

HISTORY OF PRESENT ILLNESS
Patient had onset 2 hours ago of colicky, right flank pain that radiates around to the right lower quadrant and into the urethra. Patient states urine seems to have blood in it along with the dysuria. Pain becomes more severe for 1–10 minutes and then eases off. When pain is severe, he rates it at 8 on a scale of 1–10. Patient denies fever, chills, nausea, vomiting, or diarrhea.

PAST MEDICAL HISTORY
Denies history of nephrolithiasis or cholelithiasis. Denies prior, similar episodes. No drug allergies.

EXAMINATION
Patient is a 52-year-old male, appearing intermittently uncomfortable. There is mild tenderness noted to the lower portion of the right kidney upon palpation (examination using the hands or fingers). Lungs are clear. Abdomen is soft and nontender. No suprapubic (above the pubic bone) tenderness. Extremities have good pulses without edema.

LABORATORY
Clean-catch urinalysis showed hematuria and pyuria.

DIAGNOSIS
Right ureterolithiasis.

TREATMENT PLAN
Pain subsided. However, shortly after examination severe pain returned in right flank and right lower quadrant. Patient was given ketorolac tromethamine 60 mg and sent for an IVP.


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