DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hematuria.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old lady, gravida 2. She is 24 weeks pregnant. The patient states that she had a sudden onset of gross hematuria without pain. She denies any voiding symptoms such as frequency, urgency or dysuria. She had a similar episode three weeks ago and was told that she had a kidney stone at that time. The bleeding subsided spontaneously at that time. No nausea, vomiting, fever or chills. Otherwise, no history of previous kidney stones.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: Denied.
MEDICATIONS ON ADMISSION: Denied.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse.
REVIEW OF SYSTEMS: No fever, chills, malaise. No headaches or seizures. No visual changes or eye pain. The patient wears glasses. No hearing problems or ear aches. No chest pain or palpitations. No shortness of breath or wheezing. No nausea, vomiting or abdominal pain. Genitourinary: See above. The patient denies any backaches or arthralgias. No diabetes or thyroid disease. No frequent infections. No anxiety or depression. No skin rashes or pruritus.
PHYSICAL EXAMINATION: The patient remains afebrile. Heart rate, respirations, and blood pressure were all well controlled. The patient is in no apparent distress. She is alert and oriented x3. She is cooperative, not anxious or agitated. Head and Neck: Head is normocephalic and atraumatic. Neck: Supple. Trachea is in midline. No JVD noted. Lungs: Respirations unlabored. No audible wheezing or rhonchi. Abdomen: Soft, nondistended with a gravid uterus. Extremities: Full range of motion x4. Neurologic: No focal neurological deficits noticed. Skin: Warm and dry and appears to be intact.
LABORATORY DATA: Show an essentially normal CBC, normal chemistry. Urinalysis shows pH of 7, specific gravity 1.020, 2+ albumin, 1+ bilirubin, 3+ occult blood, and trace leukocyte esterase. Microscopic shows more than 50 rbc’s per high power field, 5-10 wbc’s per high power field.
IMPRESSION: Gross painless hematuria, which has resolved. The patient appears to have some pyuria, possibly urinary tract infection. There is a question of a stone in the right kidney on ultrasound.
PLAN: Currently, the patient is asymptomatic; therefore, we recommend no further intervention at this time. The patient was instructed to follow up with the urologist. A urology appointment is pending.
Thank you, Dr. Doe, for allowing us to participate in this patient’s care.
