Urology Consult Generic

Urology Inpatient Consultation 1 November 2024 Patient: John Doe DOB: 15 March 1965 MRN#: 123456789 Reason For Consultation: Hematuria and flank pain Requesting Physician: Dr. Emily Smith Prior Urologic History: The patient has a history of recurrent kidney stones, with the last episode occurring two years ago, requiring lithotripsy. No history of urinary tract infections or other urologic surgeries. History of Present Illness: John Doe is a 59-year-old male with a PMH of hypertension, hyperlipidemia, type 2 diabetes, and recurrent nephrolithiasis, seen at the request of Dr. Emily Smith for evaluation of hematuria and flank pain. The patient reports a history of kidney stones, with previous lithotripsy performed two years ago. No recent surgeries or interventions. Past Medical History - Hypertension - Hyperlipidemia - Type 2 Diabetes - Recurrent Nephrolithiasis Past Surgical History - Lithotripsy (2 years ago) Current Medications: - Lisinopril 10 mg daily - Atorvastatin 20 mg daily - Metformin 500 mg twice daily Allergies: - Penicillin (rash) Social History - Non-smoker - Occasional alcohol use - Works as an accountant Family History - Father with history of kidney stones - Mother with hypertension Physical Exam: BP: 130/85, HR: 78, Temp: 36.8°C, RR: 16 Abdomen: Soft, non-tender, mild right flank tenderness Labs, Imaging & Other Studies: WBC: 8.5, Cr: 1.2, Urinalysis: Hematuria, Kidney ultrasound: 5mm stone in right kidney ASSESSMENT AND PLAN: 59-year-old male with recurrent nephrolithiasis and hematuria. 1. Recurrent Nephrolithiasis Assessment: The patient presents with a 5mm stone in the right kidney, consistent with previous episodes. Plan: - Increase fluid intake to 2-3 liters per day - Prescribe tamsulosin 0.4 mg daily to facilitate stone passage - Schedule follow-up in 2 weeks to reassess stone position - Discuss potential for lithotripsy if stone does not pass 2. Hematuria Assessment: Hematuria likely secondary to nephrolithiasis. Plan: - Monitor hematuria with urinalysis at follow-up - Educate patient on signs of infection or increased pain 3. Hypertension Assessment: Well-controlled on current medication. Plan: - Continue lisinopril 10 mg daily - Monitor blood pressure at home - Reassess in 3 months or sooner if symptoms change