Chapter 12: The Urinary System | Mara Rodriguez's Chart Note

CHART NOTE

Patient Name: Rodriguez, Mara
ID Number: 65588
Examination Date: August 29, 20xx

SUBJECTIVE
This 43-year-old female presents with subcostal pain and episodes of gross (visible to the naked eye) hematuria. She was seen in the ER approximately 3 weeks ago for similar symptoms. At that time a renal ultrasound was performed. It showed no evidence of hydronephrosis or renal mass. Today patient complains of some nausea and vomiting. She denies fever, chills, dysuria, or frequency. There is no previous history of urinary tract infections, calculus formation, or genitourinary (reproductive and urinary system) surgery.

OBJECTIVE
On physical examination, the abdomen appears relatively soft but diffusely tender (not limited to one location), particularly in the left upper and left lower quadrants. Some guarding was noted with no clearly elicited rebound tenderness. (When the areas were palpated, no rebound tenderness occurred when the physician's palpating hand was withdrawn.) Urinalysis today shows 6–10 erythrocytes (red blood cells) per high power field. There is no suggestion of infection with leukocytes or bacteria.

ASSESSMENT
The etiology of the pain remains unclear, although possibilities include a calculus, cholecystitis (inflammation of the gallbladder), or ovarian cyst. With absence of obstruction on the renal ultrasound, the cause of pain is not suggestive of a stone. Negative urinalysis also mitigates against pyelonephritis, and the pain is clearly abdominal. The etiology of the gross hematuria remains unclear.

PLAN
A surgical consultation for further evaluation of the abdomen is advised.