Followup Kidney Stones

SHORT SUMMARY: Mrs. Lname is a 62-year-old woman with a history of recurrent calcium oxalate kidney stones. Today's visit focuses on evaluating her current stone burden and optimising preventative measures. CHIEF COMPLAINT: Mrs. Lname is a 62-year-old woman who presents to the office today to follow up on kidney stones, for evaluation and management of their kidney stones. PAST UROLOGIC HISTORY: Mrs. Lname has a history of recurrent calcium oxalate kidney stones, with multiple episodes of renal colic requiring pain management. She underwent a ureteroscopy with laser lithotripsy five years ago. Her occupation is a teacher, and she enjoys gardening. She has no other significant urologic history. PRIOR STONE SURGERIES: * 2019: Ureteroscopy with laser lithotripsy, successful stone removal. PRIOR STONE ANALYSES: * 2019: Calcium oxalate. ALL RELEVANT IMAGING: * 2024: CT KUB showed a 5mm stone in the right kidney and a 3mm stone in the left ureter. DIETARY AND MEDICATION RISK FACTORS: * Low fluid intake. * High dietary sodium. HPI TODAY 1 November 2024: * Patient reports intermittent flank pain on the right side. * CT KUB from October 26, 2024, revealed a 5mm stone in the right kidney and a 3mm stone in the left ureter. I personally reviewed and independently interpreted the scan and concur with findings. PMH, PSH, MEDS, ALLERGIES, SH, and FH: * Reviewed and updated in EMR. PHYSICAL EXAMINATION: Constitutional: Appears comfortable. GU Exam: No CVA tenderness bilaterally. ASSESSMENT AND PLAN: Mrs. Lname, 62, with recurrent nephrolithiasis (calcium oxalate stones) and risk factors of low fluid intake and high dietary sodium. Stone composition is calcium oxalate. 1. Kidney Stones (N20.0) Assessment: Current stone burden includes a 5mm stone in the right kidney and a 3mm stone in the left ureter. Risk factors include low fluid intake and high dietary sodium. Plan: Increase fluid intake to 2-3 litres per day. Reduce sodium intake. Follow-up CT KUB in 6 months. Counseling: Discussed dietary modifications and importance of adequate hydration. ORDERS: * Repeat CT KUB in 6 months. FOLLOW-UP: Follow-up in 6 months for repeat imaging. SHORT SUMMARY: Mrs. Lname is a 62-year-old woman with a history of recurrent calcium oxalate kidney stones. Today's visit focuses on evaluating her current stone burden and optimising preventative measures. “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”