REASON FOR CONSULTATION: Urologic opinion regarding urinary tract infection and hydronephrosis.
CHIEF COMPLAINT: Urinary tract infection.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old female seen in the company of her daughter today. The patient began complaining of some vague abdominal pain last Thursday. This was more on the right side than the left. This pain was dull in quality. The severity was mild to moderate. Nothing seemed to make it better or worse. It was not associated with gross hematuria, bone pain, weight loss, night sweats, fevers or chills but did become associated with some changes in mental status. She denies prior flank pain. She has had urinary tract infections in the past.
PAST MEDICAL HISTORY: Significant for anemia.
PAST SURGICAL HISTORY: Significant only for right orthopedic wrist surgery.
ALLERGIES: She has no known drug allergies.
CURRENT MEDICATIONS: Include aspirin, cefepime, potassium chloride, acetaminophen, carvedilol, heparin, morphine, Levaquin, and temazepam.
REVIEW OF SYSTEMS: Other than that stated in the HPI, negative by 13 systems other than some nausea and vomiting.
GENERAL: She is awake and alert. She seems to be oriented to person and place, if not situation.
HEENT: Normocephalic, atraumatic. Pupils were equal, round and reactive to accommodation.
NECK: Supple. Thyroid unremarkable. No obvious supraclavicular lymphadenopathy.
CV: S1, S2. No obvious overt murmurs, rubs or gallops.
LUNGS: Clear bilaterally with no obvious rales, crackles or wheezes. Breath sounds are equal. She has no labored breathing.
ABDOMEN: Soft, nontender, nondistended. We do not appreciate abdominal masses or hepatosplenomegaly. She has no overt CVA tenderness to percussion bilaterally. She has no abdominal incisions. Bowel sounds present in all 4 quadrants. Bladder is not palpable above the pubic symphysis.
EXTREMITIES: Free of overt clubbing, cyanosis or edema.
She has clear yellow urine in her catheter, which appears to be in good position.
CT scan is reviewed without contrast. Her bladder is collapsed around the Foley catheter. We do not see any overt abnormalities of the left kidney or either ureter, although this is a non-contrast study. The right kidney has hydronephrosis and the appearance of UPJ obstruction with a possible crossing vessel, again although this is a non-contrast study. We do not appreciate any overt stones.
LABORATORY REVIEW: White count today is 29, H&H 8.9 and 27.6, platelets are 212. Creatinine today is 1.7.
UA from (XX) is positive for nitrites, 2+ leukocyte esterase, pH of 5.5. Microscopically, there are 5 to 10 red blood cells per high-powered field, 10 to 30 white blood cells per high-powered field, 2+ bacteria.
Urine culture is positive for greater than 100,000 colony forming units per mL of E. coli. Sensitivities are pending.
Blood cultures are positive for gram negative rods.
Urine output recorded through the last three shifts is 254, 100, and 75.
ASSESSMENT: The patient is a pleasant (XX)-year-old female with a urinary tract infection, bacteriuria, abdominal pain, and right-sided hydronephrosis.
PLAN:
1. Abdominal pain: This is likely from her urinary tract infection and could be related to her hydronephrosis. See below.
2. Urinary tract infection: We are deferring treatment of this to her primary team. Certainly, she is on reasonable empiric antibiotics.
3. Right-sided hydronephrosis: We spent greater than 70 minutes in consultation with the patient and her daughter today, greater than 50% spent in direct face-to-face counseling and planning, discussing these issues.
4. As far as her hydronephrosis is concerned, this is most likely longstanding and less likely acute. We talked to them about the following options to address this, each discussed with her, concomitant risks and benefits:
a) Observation.
b) Performance of cystoscopy with attempt at a right double-J ureteral stent placement to unobstruct her right kidney under anesthesia.
c) Placement of right percutaneous nephrostomy tube placement with or without attempted antegrade stent placement.
5. After discussing all of these options, the patient and the daughter at this point would like to just follow things clinically, and if she continues to improve, then they would like to address this on an outpatient basis.
6. Certainly, we explained to them in no uncertain terms that if this infection is in her right kidney, then unobstructing the kidney will certainly hasten her recovery and may even be integral to her ability to recover from this infection. They understand that the decision to do nothing at this point could give her a higher chance of having complications in the way of morbidity and even potentially mortality.
7. We will discuss this with Dr. (XX) and we will be following along, should the patient decide that they would like to undergo intervention especially.
8. We did talk to them about potential repair of UPJ obstruction but explained to them that there would need to be further workup and several other steps taken before entertaining that sort of issue.
9. At the conclusion of the visit, the patient and her daughter stated all of their questions were answered. They participated fully in the medical decision-making process.
