Calculus of ureter Acute kidney failure unspecified Hydronephrosis Cystitis cystica Chronic kidney disease unspecified Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Unspecified essential hypertension Other and unspecified hyperlipidemia Obesity unspecified Body Mass Index 34.0-34.9 adult
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: UROLOGY
 
Allergies: 
Gentamicin
 
Attending: ___.
 
Chief Complaint:
L flank pain
 
Major Surgical or Invasive Procedure:
cystoscopy, L retrograde pyelogram, ureteral stent placement

 
History of Present Illness:
___ 1.6 cm obstructing stone on the left with cranial 
outpatient. Patient reports that for the past several weeks and 
increasing left flank pain, seen by nephrology, recommended an 
ultrasound demonstrating obstructing stone with hydronephrosis. 
Creatinine noted to be elevated, referred here for evaluation. 
Patient's history of complicated nephrolithiasis on the 
contralateral side last year which was intervened upon by 
lithotripsy. Patient denies this time fevers or chills, no back 
pain. Patient reports that she has decreased appetite, however 
has no pain. 

CT scan in the ED demonstrated two obstructing L UPJ stones with 
hydro.
 
Past Medical History:
-Nephrolithiasis
-Hypertension
-Type II Diabetes Mellitus
-Hyperlipidemia
 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
NAD
abd soft, NT,ND
no rebound or guarding
no cva bilaterally
 
Brief Hospital Course:
Patient was admitted to Urology for pain control and 
observation.  On HD2 the patient underwent a cystoscopy, L 
retrograde pyelogram and stent placement. Please see dictated 
operative note for details.  Following the procedure the patient 
was tolerating aregular diet and voiding without any problems.  
She was discharged home the same day as her procedure with 
instructions to ___ with a BMP on ___.  
Patient will see Dr. ___ in ___ weeks for 
discussion about lithotripsy for her stones.
 
Medications on Admission:
 amlodipine 
amlodipine 10 mg tablet
1 Tablet(s) by mouth once a day  ___
Renewed ___,
 ___ 30 Tablet 5   ___ Care) 
 
  atenolol 
atenolol 50 mg tablet
1 Tablet(s) by mouth once a day  ___
Renewed ___,
 ___ 30 Tablet 5   ___ NP
___ Care) 
 
  atorvastatin [Lipitor] 
Lipitor 20 mg tablet
1 Tablet(s) by mouth once a day  ___
Renewed ___,
 ___ 30 Tablet 5   ___ NP
___ Care) 
 
nr diabeton 

30 mg a day in the morning Medication is not available in the 
___, brought from ___ (Prescribed by Other Provider)  
___
Recorded Only ___,
 ___         
 
  ibuprofen 
ibuprofen 600 mg tablet
1 tablet(s) by mouth three times a day  ___
___,
 ___ 20 Tablet 0   ___ Care) 
 
  lisinopril 
lisinopril 20 mg tablet
one Tablet(s) by mouth once a day  ___
Renewed ___,
 ___ 30 Tablet 5   ___ NP
___ Care) 
 
  metformin 
metformin 1,000 mg tablet
1 Tablet(s) by mouth twice a day  ___
Renewed ___,
 ___ 60 Tablet 5   ___ NP
___ Care) 
 
  potassium citrate 
potassium citrate ER 10 mEq (1,080 mg) tablet,extended release
1 Tablet(s) by mouth twice a day  

 
Discharge Medications:
same
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
L renal stone

 
Discharge Condition:
stable

 
Discharge Instructions:
-Please have your blood drawn on ___ at ___.  We 
have included a prescription for the blood draw with your 
discharge materials.

-Expect to see occasional blood in your urine and to experience 
urgency and frequecy over the next month.
 
-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthough pain >4.  
Replace Tylenol with narcotic pain medication.  Max daily 
Tylenol dose is 4gm, note that narcotic pain medication also 
contains Tylenol (acetaminophen)

 
Followup Instructions:
___

{'flank pain': ['Calculus of ureter', 'Hydronephrosis'], 'elevated creatinine': ['Acute kidney failure', 'Chronic kidney disease'], 'decreased appetite': ['Diabetes mellitus without mention of complication', 'type II or unspecified type'], 'no cva bilaterally': ['Unspecified essential hypertension', 'Other and unspecified hyperlipidemia'], 'soft abdomen': ['Obesity', 'unspecified', 'Body Mass Index 34.0-34.9', 'adult']}