Flank Pain – Consult

CHIEF COMPLAINT: 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: ADHD.

SOCIAL 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.