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Report #3 Discharge Summary (5 errors inthis report)

Case History: This 32-year-old single whitemale, appearing his stated age, was admitted to the hospital afterpresenting to the emergency room in acute distress. He complainedof intermittent pain in the right posterior lumbar area radiatingto the right flank. He has a family history of pyelolithiasis andhas been treated for this condition several times in the past tenyears.

Discharge Summary: This patient was admitted tothe endocrinology unit from the emergency room, complaining ofsevere intermittent pain the back and right flank. His KUB showedone calculi in the region of the right renal pelvis. Laboratorydata were all normal except for slight microscopic hematuria. Anintravenous pyelogram showed three stones in the right gallbladderwith minimal hydronephrosis. A right retrograde pyelogram confirmedpresence of three stones in the left kidney. Minimal ureteralobstruction was present. Incision into the renal pelvis wascompleted with no complication. A ureteral catheter was inserted aswas an indwelling Foley catheter. Drainage from the right kidneywas pale yellow in forty-eight hours. These catheters were removedthree days postoperatively. At discharge, the patient is voidingwithout difficulty, is febrile with a temperature of 98.6°, andambulatory. The stones were sent to the laboratory for analysis.The report indicated that they were composed of calcium. He isdischarged to his home on restricted activity for the next twoweeks. He is advised to drink a large amount of fluid. He will befollowed in the office in three weeks.

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Deanna Hettinger
Deanna HettingerLv2
28 Sep 2019

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