Female Patient (Urology)

PCP: Dr. Sarah Johnson CHIEF COMPLAINT: 1. Nephrolithiasis (Allergies: Penicillin, On blood thinner: Warfarin for atrial fibrillation) The patient is a 45-year-old nurse who works in a high-stress environment. She is accompanied by her husband, John, who has been present in previous visits and assists in providing her medical history. "Since our last visit," the patient has not had any emergency department visits, surgeries, or hospitalizations. She reports no changes in her non-urologic medications. 1. Urological Issue or Condition NEPHROLITHIASIS: The patient reports no new stone problems since the last visit. She has not experienced hematuria or infections. Today the patient is here to review imaging from 15 October 2024, a CT stone scan. I have personally reviewed those imaging results. Notable findings include: a 3mm stone in the left kidney with no hydronephrosis. History of prior surgeries and imaging: - 10 March 2023, ESWL - 5 June 2023, CT stone Stone Diet: Fluid intake: 2 liters per day Brown Sodas / Sugary Beverages: None Salt Intake: Moderate Meats/Proteins: High Oxalate Containing foods: Moderate Dairy/Calcium: 2 servings per day Supplemental Vitamins: None URINARY SYMPTOMS: Current medications: Oxybutynin 5mg daily, Vaginal estrogen cream Past medications: Tolterodine (stopped due to dry mouth) Currently during the day, the patient urinates with a frequency of: every 2 hours (last visit every 3 hours) On an average night, the patient wakes to urinate: 2 times (last visit every 3 hours) With regards to urinary urgency: moderate, unchanged from last visit History of stress urinary incontinence with cough, sneeze, and valsalva: Yes History of urge incontinence when they cannot make it to the bathroom on time: Yes For incontinence, the patient wears following pads: Light pads PVR History: - 1 November 2023, 50ml - 1 November 2024, 40ml Investigations: - 1 November 2024, Urodynamic test: Normal With regards to diet: Amount of fluid during day: 2 liters Caffeine intake: minimal Carbonated Beverage intake: minimal Acidic foods: minimal Alcohol: average Spicy Foods: minimal Number of children: 2, both vaginal deliveries, no complications Menses: post-menopause Significant Gynecologic History: Hysterectomy in 2018 The patient is sexually active and reports that they have mild problems with vaginal dryness. History of problems with constipation: None PERTINENT PMH/PSH/MEDS PMH: Diabetes, OSA (uses CPAP), Low back problems PSH: Hysterectomy, ESWL MEDS: Metformin, Warfarin, Oxybutynin, Vaginal estrogen cream SOCIAL HISTORY: Non-smoker, moderate alcohol use, nurse Allergies: Penicillin PHYSICAL EXAM: General: Patient is well-developed, well-nourished, and in no apparent distress. Neuro: Alert. Affect is appropriate. Lungs: No respiratory distress, no intercostal retractions, no use of accessory muscles. Extremities: Lower extremities without notable edema. GU Exam: - Prior GU exam: Normal, March 2023 Assessment & Plan: 1. Nephrolithiasis - Assessment: Likely diagnosis of stable nephrolithiasis with a 3mm stone in the left kidney. - Shared Decision Conversation: Discussed options of observation versus intervention. Patient opted for observation with dietary modifications. - Investigations planned: Follow-up imaging in 6 months. - Medical treatment planned: Continue current medications, increase fluid intake. - Lifestyle modifications: Reduce protein intake, increase fluid intake. - Follow-up appointments: Review in 6 months with repeat imaging. SHORT SUMMARY: The patient presents with stable nephrolithiasis and urinary symptoms. A shared decision was made to continue observation with dietary modifications and follow-up imaging in 6 months.