Initial
consideration in this patient included ureteral/kidney stone, urinary tract
infection (UTI), pelvic inflammatory disease (PID), pyelonephritis, testicular
torsion, back pain (including herniated disc, musculoskeletal causes, and cauda
equina), and sexually transmitted infections among others.
Patient presented with [left/right/bilateral] flank pain with report of [prior/no prior]
episodes of kidney stones [additional details].
Patient was noted to have hematuria on urinalysis without findings
suggestive of UTI.
Patient without fever or other systemic infectious symptoms. [Formal/Bedside] ultrasound obtained with [no/evidence of stone/hydronephrosis]. Based on lack of evidence of hydronephrosis [in a patient with a history of passing prior stones without intervention], it was felt that the stone had a high likelihood of passing without intervention.
CT was obtained with evidence of [describe
stone], and [with/without significant] hydronephrosis. Based on stone size [1-4 mm (78% passage rate)/5-7 mm (60% passage rate/>8 mm (39% passage rate) it was felt
that the stone had a high likelihood of passing without intervention/a consult was placed for Urology follow up/case was discussed with Dr. NAME of Urology]. Negative pregnancy test in the ED making
pregnancy-related complications unlikely.
No significant pelvic pain, vaginal bleeding, or vaginal discharge to
suggest PID. Labs were obtained and [noted to be unremarkable/notable for specific abnormalities]. Pain improved with [Kertorolac (Toradol)/intravenous lidocaine/opioids] in
the ED. [ Discussed with Dr. [NAME] of Urology with discuss recommendation]. Referral placed for Urology follow up, and discussed with patient prior
to discharge.
Discussed return precautions,
specifically for evidence of infected stone or worsening pain, treatment with
analgesics and [Tamsulosin (Flomax)], and follow up with primary care doctor within [2-3
days/1 week] and Urology [at the next available appointment/time/date] for
further evaluation, and the patient demonstrated understanding and agreement.
At World of Urology, our Kidney Stone Doctors specialize in diagnosing and treating kidney stones with advanced, minimally invasive procedures. With expert care and state-of-the-art technology, we ensure effective stone removal and long-term kidney health. Trust our experienced team for personalized treatment and rapid relief from kidney stone discomfort.
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