Calculus of kidney Hydronephrosis Fever unspecified Other specified retention of urine Acute kidney failure unspecified Urinary tract infection site not specified Hypertensive chronic kidney disease unspecified with chronic kidney disease stage I through stage IV or unspecified Chronic kidney disease unspecified Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Other and unspecified hyperlipidemia
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: UROLOGY
 
Allergies: 
Gentamicin
 
Attending: ___.
 
Chief Complaint:
Fever
 
Major Surgical or Invasive Procedure:
None this admission, however, recent procedure ___:  
Cystoscopy, left retrograde pyelogram, left ureteroscopy, left 
laser lithotripsy and basket extraction of stone, and left 
ureteral stent exchange.

 
History of Present Illness:
___ with h/o nephrolithiasis s/p L laser litho, stent 
placement today c/b post-op urinary retention requiring foley 
placement returning to the ED with fevers at home.  

In the ED patient with temp of 100.9 with chills.  She was given 
1gm ceftriaxone and admitted to urology for observation.  
Patient states that foley was draining well at home, although 
renal US in the ED demonstrated a partially full bladder.  Thus, 
she was admitted for IV antibiotics and observation.
 
Past Medical History:
PMH: 
-Nephrolithiasis
-Hypertension
-Type II Diabetes Mellitus
-Hyperlipidemia

Allergies:
Gentamicin

PSH:
Emergent left ureteral stent placement
Left ureteroscopy, laser lithotripsy, basket extraction, stent 
exchange
 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
Afeb, VSS
Wd Obese female ___ speaking, NAD
Unlabored breathing
Soft abdomen, nttp, no CVAT
Stent string fastened onto pubic area
Ext WWP, no edema
 
Pertinent Results:
___ 06:40AM BLOOD WBC-8.8 RBC-3.62* Hgb-10.4* Hct-32.0* 
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.1 Plt ___
___ 08:05AM BLOOD WBC-15.6* RBC-4.12* Hgb-11.7* Hct-36.4 
MCV-88 MCH-28.3 MCHC-32.0 RDW-15.1 Plt ___
___ 09:40PM BLOOD WBC-14.1*# RBC-3.99* Hgb-11.4* Hct-34.6* 
MCV-87 MCH-28.7 MCHC-33.0 RDW-15.1 Plt ___
___ 09:40PM BLOOD Neuts-90.5* Lymphs-5.0* Monos-2.9 Eos-1.2 
Baso-0.4
___ 06:40AM BLOOD Glucose-127* UreaN-17 Creat-1.5* Na-143 
K-3.9 Cl-105 HCO3-27 AnGap-15
___ 09:40PM BLOOD Glucose-201* UreaN-22* Creat-1.5* Na-140 
K-4.3 Cl-104 HCO3-25 AnGap-15

Urine:
GENERAL URINE ___
___ ___   YellowHazy1.009

DIPSTICK 
U
R
I
N
A
L
Y
S
ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks

___ 21:36  LGNEG100NEGNEGNEGNEG5.5LG
MICROSCOPIC URINE 
EXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp
___ 21:36  >182*>182*FEWNONE0  

Urine culture:
                **FINAL REPORT ___

   URINE CULTURE (Final ___:    <10,000 organisms/ml. 
 
Brief Hospital Course:
The pateint was admitted to Urology service for fevers after 
being recently discharged earlier that day from an outpatient 
procedure - left ureteroscopy, laser lithotripsy, basket 
removal, and stent exchange. No concerning intraoperative events 
occurred; please see dictated operative note for details.  She 
received intravenous fluids and antibiotics (Ceftriaxone).  On 
POD2, the Foley was removed after active voiding trial and post 
void residuals were checked. She was tolerating a regular diet, 
ambulating without difficulty.  On POD3, her urine culture 
revealed <10,000 organisms.  She was afebrile with stable vital 
signs.  She was discharged home with 7 days of ciprofloxacin, 
and instructed to follow up with Dr. ___ stent removal 
in 3 days.  Her creatinine was 1.5, and she was instructed to 
hold her metformin, unless her surgars are greater than 200.  
She was instructed to eat a diabetic diet, and to check her 
sugars regularly.  She will follow up with her PCP office early 
this week.  

 
Medications on Admission:
Metformin 
Amlodipine 10 mg PO DAILY 
Atenolol 50 mg PO DAILY 
Atorvastatin 20 mg PO DAILY 
Tamsulosin 0.4 mg PO DAILY 
Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
Metformin 1000 bid
 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain,fever 
2. Amlodipine 10 mg PO DAILY 
3. Atenolol 50 mg PO DAILY 
4. Atorvastatin 20 mg PO DAILY 
5. Tamsulosin 0.4 mg PO DAILY 
6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain 
7. Ciprofloxacin HCl 500 mg PO Q12H 
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) 
hours Disp #*14 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
ADMISSION DIAGNOSIS:  Post-operative fever

PREOPERATIVE DIAGNOSES:  Proximal left ureteral calculus
approximately 8 mm in size, acute-on-chronic renal
insufficiency, status post emergent ureteral stent placement.

POSTOPERATIVE DIAGNOSES:  1 cm renal calculus.

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
-You can expect to see occasional blood in your urine and to 
possibly experience some urgency and frequency over the next 
month;  this may be related to the passage of stone fragments or 
the indwelling ureteral stent (if there is one).

-The kidney stone may or may not have been removed AND/or there 
may fragments/others still in the process of passing.

-You may experience some pain associated with spasm of your 
ureter.; This is normal. Take the narcotic pain medication as 
prescribed if additional pain relief is needed.

-Ureteral stents MUST be removed or exchanged and therefore it 
is IMPERATIVE that you follow-up as directed. 

-Do not lift anything heavier than a phone book (10 pounds) 

-You may continue to periodically see small amounts of blood in 
your urine--this is normal and will gradually improve

-Resume all of your pre-admission medications, except HOLD 
aspirin until you see your urologist in follow-up AND your foley 
has been removed (if not already done)

-You may or may not have passed all your stones

****Ureteral stent

-You MAY be discharged home with a medication called PYRIDIUM 
that will help with the "burning" pain you may experience when 
voiding. This medication may turn your urine bright orange.

-Colace has been prescribed to avoid post surgical constipation 
and constipation related to narcotic pain medication. 
Discontinue if loose stool or diarrhea develops. Colace is a 
stool softener, NOT a laxative, and available over the counter.  
The generic name is DOCUSATE SODIUM.  It is recommended that you 
use this medication.

-Do not eat constipating foods for ___ weeks, drink plenty of 
fluids to keep hydrated

-No vigorous physical activity or sports for 4 weeks and if 
there is a Foley catheter is in place.

-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthrough pain >4. 
Replace Tylenol with narcotic pain medication.

-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL 
sources, note that narcotic pain medication also contains 
Tylenol

-Do not drive or drink alcohol while taking narcotics and do not 
operate dangerous machinery. Also, if the Foley catheter and Leg 
Bag are in place--Do NOT drive (you may be a passenger).
 
Followup Instructions:
___

{'Fever': ['Post-operative fever', 'Urinary tract infection'], 'Chills': ['Post-operative fever', 'Urinary tract infection'], 'Hypertension': ['Hypertensive chronic kidney disease'], 'Type II Diabetes Mellitus': ['Diabetes mellitus without mention of complication'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Nephrolithiasis': ['Calculus of kidney'], 'Urinary retention': ['Other specified retention of urine'], 'Acute kidney failure': ['Acute kidney failure'], 'Hydronephrosis': ['Hydronephrosis']}