History and Physical DATE OF ADMISSION: MM/DD/YYYY HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old white male who we

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History and Physical DATE OF ADMISSION: MM/DD/YYYY HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old white male who went to the emergency room with sudden onset of severe left flank and left lower quadrant abdominal pain associated with gross hematuria. The patient had a CT stone profile which showed no evidence of renal calculi. He was referred for urologic evaluation. When seen in our office, the patient continued to have mild left flank pain and no difficultly voiding. Urinalysis showed 1+ occult blood. Intravenous pyelogram was done which demonstrated a low-lying malrotated right kidney. There was no evidence of renal or ureteral calculi or hydronephrosis. Urine cytology was negative for malignant cells. The patient subsequently had a CT renal scan with contrast. This showed what appeared to be an infarction of an area of the lower pole of the left kidney. It was suggested that a renal MRI be done for further delineation of this problem. He had a right kidney which was malrotated but was otherwise normal. The patient is admitted at this time for complete urologic evaluation. PAST MEDICAL HISTORY: He had surgery on his right knee two years ago. MEDICATIONS: He takes: 1. Diovan 80 mg with hydrochlorothiazide 12.5 mg daily. 2. Hydrocodone as needed for pain. ALLERGIES: There are no known drug allergies. SOCIAL HISTORY: He is single. Denies use of alcohol. Smokes one pack of cigarettes per day over the last 10 years. FAMILY HISTORY: Father died of cancer, type unknown. Mother is living and well. REVIEW OF SYSTEMS: Neurologic: Denies vertigo, syncope, convulsions or headaches. Musculoskeletal: No muscle or joint pain. Cardiorespiratory: Denies shortness of breath, dyspnea on exertion, chest pain, cough or hemoptysis. Gastrointestinal: He has occasional indigestion. Denies emesis, melena, constipation, diarrhea or rectal bleeding. Genitourinary: As noted in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse is 72 and regular, respirations 18 and regular, blood pressure 122/78. GENERAL: Well-developed, well-nourished white male in no acute distress. Alert and cooperative HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear. Tympanic membranes are normal. NECK: Supple. No thyromegaly. No cervical adenopathy. CHEST: Symmetrical with equal expansion. LUNGS: Clear to percussion and auscultation. HEART: No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm. ABDOMEN: There is slight left flank tenderness to deep palpation. There is no guarding or rebound tenderness. Bowel sounds are normal. EXTREMITIES: No peripheral edema or varicosities. GENITALIA: Normal external male genitalia. No penile lesions. Testes are descended bilaterally and are normal to palpation. RECTAL: The prostate is small, benign and nontender
IMPRESSION: Hematuria associated with left flank pain and left renal infarction. PLAN: Admitted at the present time for further evaluation.
Case Study Rubric Criteria Ratings Pts Accuracy of Information 5 pts All case studies are Identified by title and medical terms are translated correctly using basic language. 3 pts All medical terms are translated correctly, however, the title of the case is missing or the paragraphs are disjointed and do not flow well or basic language is not used. O pts Not all medical terms are translated or too complicated language is used. 5 pts 5 pts Grammar Punctuation, & Spelling Assignment is written with no errors in grammar, spelling, or punctuation 3 pts Assignment is written with several errors in grammar, puctuation, and spelling, O pts Assignment has many errors in grammar, punctuation, & spelling 5 pts Depth & Breadth 10 pts All areas of the medical report have been addressed in full paragraph form. A non-medical person should be able to read the report and have a complete understand of all aspects within the report including pertinent translations, orientations of body parts, importance, test results, medication interactions, etc... 5 pts Areas of the medical report are address, but are not complete or do not have all pertinent Information available. O pts No areas of the medical report were easy to read or did not contain needed Information 10 pts Total Points: 20
History and Physical DATE OF ADMISSION: MM/DD/YYYY HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old white male who went to the emergency room with sudden onset of severe left flank and left lower quadrant abdominal pain associated with gross hematuria. The patient had a CT stone profile which showed no evidence of renal calculi. He was referred for urologic evaluation. When seen in our office, the patient continued to have mild left flank pain and no difficultly voiding. Urinalysis showed 1+ occult blood. Intravenous pyelogram was done which demonstrated a low-lying malrotated right kidney. There was no evidence of renal or ureteral calculi or hydronephrosis. Urine cytology was negative for malignant cells. The patient subsequently had a CT renal scan with contrast. This showed what appeared to be an infarction of an area of the lower pole of the left kidney. It was suggested that a renal MRI be done for further delineation of this problem. He had a right kidney which was malrotated but was otherwise normal. The patient is admitted at this time for complete urologic evaluation. PAST MEDICAL HISTORY: He had surgery on his right knee two years ago. MEDICATIONS: He takes: 1. Diovan 80 mg with hydrochlorothiazide 12.5 mg daily. 2. Hydrocodone as needed for pain. ALLERGIES: There are no known drug allergies. SOCIAL HISTORY: He is single. Denies use of alcohol. Smokes one pack of cigarettes per day over the last 10 years. FAMILY HISTORY: Father died of cancer, type unknown. Mother is living and well. REVIEW OF SYSTEMS: Neurologic: Denies vertigo, syncope, convulsions or headaches. Musculoskeletal: No muscle or joint pain. Cardiorespiratory: Denies shortness of breath, dyspnea on exertion, chest pain, cough or hemoptysis. Gastrointestinal: He has occasional indigestion. Denies emesis, melena, constipation, diarrhea or rectal bleeding. Genitourinary: As noted in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse is 72 and regular, respirations 18 and regular, blood pressure 122/78. GENERAL: Well-developed, well-nourished white male in no acute distress. Alert and cooperative HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear. Tympanic membranes are normal. NECK: Supple. No thyromegaly. No cervical adenopathy. CHEST: Symmetrical with equal expansion. LUNGS: Clear to percussion and auscultation. HEART: No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm. ABDOMEN: There is slight left flank tenderness to deep palpation. There is no guarding or rebound tenderness. Bowel sounds are normal. EXTREMITIES: No peripheral edema or varicosities. GENITALIA: Normal external male genitalia. No penile lesions. Testes are descended bilaterally and are normal to palpation. RECTAL: The prostate is small, benign and nontender
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Case Study Rubric Criteria Ratings Pts Accuracy of Information 5 pts All case studies are Identified by title and medical terms are translated correctly using basic language. 3 pts All medical terms are translated correctly, however, the title of the case is missing or the paragraphs are disjointed and do not flow well or basic language is not used. O pts Not all medical terms are translated or too complicated language is used. 5 pts 5 pts Grammar Punctuation & Spelling O pts Assignment is written with no errors in grammar, spelling, or punctuation, 3 pts Assignment is written with several errors in grammar, puctuation, and spelling, Assignment has many errors in grammar, punctuation, & spelling 5 pts Depth & Breadth 10 pts All areas of the medical report have been addressed in full paragraph form. A non-medical person should be able to read the report and have a complete understand of all aspects within the report including pertinent translations, orientations of body parts, importance, test results, medication interactions, etc... 5 pts Areas of the medical report are address, but are not complete or do not have all pertinent Information available O pts No areas of the medical report were easy to read or did not contain needed information 10 pts Total Points: 20
IMPRESSION: Hematuria associated with left flank pain and left renal infarction. PLAN: Admitted at the present time for further evaluation.