Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Ureteral Calculus - Consult
Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.
(Medical Transcription Sample Report)
Right distal ureteral calculus.HISTORY OF PRESENT ILLNESS:
The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.PAST MEDICAL HISTORY:
2. Coronary artery disease.PAST SURGICAL HISTORY:
1. Right spermatocelectomy.
2. Left total knee replacement in 1987.
3. Right knee in 2005.MEDICATIONS:
1. Coumadin 3 mg daily.
3. Viagra p.r.n.ALLERGIES:
NONE.REVIEW OF SYSTEMS:
CARDIOPULMONARY: No shortness of breath or chest pain. GI: No nausea, vomiting, diarrhea or constipation. GU: Voids well. MUSCULOSKELETAL: No weakness or strokes.FAMILY HISTORY:
GENERAL APPEARANCE: An alert male in no distress.
HEENT: Grossly normal.
HEART: Normal sinus rhythm. No murmur or gallop.
ABDOMEN: Soft. No masses.
GENITALIA: Normal penis. Testicles descended bilaterally.
RECTAL: Examination benign.
EXTREMITIES: No edema.IMPRESSION:
Right distal ureteral calculus.PLAN:
Right ureteroscopy, ureteral lithotripsy. Risks and complications discussed with the patient. He signed a true informed consent. No guarantees or warrantees were given.
consult - history and phy., stent, calcification, ct urogram, ureteral calculus, distal ureteral, kub, teardrop, ureteroscopy, lithotripsy, calculus, hematuria,
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