CONSULTATION Apparently, this patient presented to the emergency room last night, about midnight, with excruciating left

flank pain radiating down into the left groin and testicle, chills, nausea, vomiting, and slight urinary burning, all of about 2 hourshours( 0.50, FORMAT ERROR) duration, and a (0.25, ARTICLE OMISSION) stat urine in the ER showed 60 to 80 red cells. Apparently, he was given Stadol 2 mg, IM for analgesia and some IV fluidfluids (0.50, PLURAL FORM), and he had an emergency IVP run, which showed a radiopaque stone measuring about 1/2-0.5 (0.50, FORMAT ERROR)cm partially blocking the left ureter at a point about 3 cm below the UP junction. There was moderate hydronephrosis without appreciable dilatation of the caliceal system, and some dye was getting down into the distal ureter. I have reviewed these films, and they show a normal urinary tract anatomy on the right and on the left except as noted. When I examined him about 10 a.m., he was still in considerable distress, although noticeably obtunded by a dose of Demerol given about 1/2-one-half (0.50, FORMAT ERROR)hour prior to my visit. He was sufficiently alert, however, to give a good (1.50, ENGLISH WORD OMISSION0 clear history. Apparently, this man has had 2 previous episodes of left-sided ureteral colic followed by spontaneous passage of stones. Once a , once while on military service in turkeyTurkey (0.50, CAPITA;IZATION ERROR) and once since then, but on neither occasion were the stones preserved for analysis. His general health is good, and he takes no medicine. He has never had a urinary tract infection. There is no known family history of renal lithiasis, gout, or bone or joint disease,; however, he is adopted. He is 41 years of age, married, with 2 daughters, and is employed as a manager of a bowling alley. EXAMINATION: TempTemperature (0.50, FORMAT ERROR) is 99.2, pulse 100, blood pressure 150/80. Physical exam is quite benign except that he is pale, sweating, restless, and in considerable distress and tender at the left CVA and in the left upper quadrant over the kidney and ureter. External genital exam is unremarkable. I did not attempt to do a rectal exam, as he has an IV running even though he is now taking oral fluids and he is not nauseated. He is boardingvoiding (1.50, INCORRECT ENGLISH WORD) painlessly, and his urine is being strained. I did not see his urine, but according to the patient and the attendant, it is not grossly bloody. DIAGNOSIS: Left ureteral lithiasisureterolithiasis (3.00, INCORRECT MEDICAL TERM) with partial ureteral obstruction and hydronephrosis. RECOMMENDATIONS: 1. Continue analgesia and hydration. 2. Continue straining urine and preserve any solid material passpassed (0.50, WRONG TENSES) for chemical analysis. 3. Clean-voided midstream urine for culture and sensitivity. 4. After these havethis has (0.50, GRAMMAR ERROR) been obtained, start Cipro 500 mg q .12 .h. orally. 5. He is now about 12 hours post onset of symptoms, but there is still a good statistical chance that he will pass his stonesstone (0.50, SINGULAR FORM) spontaneously. We are going to get another IVP at 4 p.m., and if he ishes (0.50, FORMAT ERROR)still obstructed, I think we would (1.50, ENGLISH WORD OMISSION) better attempt to bring this stone down with a snare before he gets enough local edema to obstruct completely or gets into trouble with a red -hot ascending pyelonephritis.

6. In any event, he needneeds (0.50, PLURAL FORM) a biochemical diagnosis of his problem, and depending on that, he may need dietary or drug prophylaxis against future calculus disease. Thank you for the privilege of collaborating in the care of this patient.

NP: 13.25 LC: 48.85 QA: 72.88%