Sample Name: Ureteral Calculus - Consult
Description: 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)
CHIEF COMPLAINT: 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.
3. Right knee in 2005.
1. Coumadin 3 mg daily.
3. Viagra p.r.n.
FAMILY HISTORY: Noncontributory.
GENERAL APPEARANCE: An alert male in no distress.
HEENT: Grossly normal.
HEART: Normal sinus rhythm. No murmur or gallop.
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.
Keywords: urology, stent, calcification, ct urogram, ureteral calculus, distal ureteral, kub, teardrop, ureteroscopy, lithotripsy, calculus, hematuria,