Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Flank Pain - Consult
Left flank pain and unable to urinate.
(Medical Transcription Sample Report)
Left flank pain and unable to urinate.HISTORY:
The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X.MEDICATIONS:
Ritalin 50 a day.ALLERGIES:
To penicillin.PAST MEDICAL HISTORY:
No smoking, alcohol, or drug abuse.PHYSICAL EXAMINATION:
She is awake, alert, and quite comfortable. Abdomen is benign. She points to her left flank, where she was feeling the pain.DIAGNOSTIC DATA:
Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.LABORATORY WORK:
Showed white count 6200, hematocrit 44.7. Liver function tests and amylase were normal. Urinalysis 3+ bacteria.IMPRESSION:
1. Left flank pain, question etiology.
2. No evidence of surgical pathology.
3. Rule out urinary tract infection.PLAN:
1. No further intervention from my point of view.
2. Agree with discharge and followup as an outpatient. Further intervention will depend on how she does clinically. She fully understood and agreed.
consult - history and phy., flank pain, unable to urinate, urinary tract infection, flank,
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