Ureteral Calculus – Consult

CHIEF COMPLAINT: Right distal ureteral calculus.

HISTORY OF PRESENT ILLNESS: The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.

PAST MEDICAL HISTORY:
1. Prostatism.
2. Coronary artery disease.

PAST SURGICAL HISTORY:
1. Right spermatocelectomy.
2. Left total knee replacement in 1987.
3. Right knee in 2005.

MEDICATIONS:
1. Coumadin 3 mg daily.
2. Fosamax.
3. Viagra p.r.n.

ALLERGIES: NONE.

REVIEW OF SYSTEMS: CARDIOPULMONARY: No shortness of breath or chest pain. GI: No nausea, vomiting, diarrhea or constipation. GU: Voids well. MUSCULOSKELETAL: No weakness or strokes.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: An alert male in no distress.
HEENT: Grossly normal.
NECK: Supple.
LUNGS: Clear.
HEART: Normal sinus rhythm. No murmur or gallop.
ABDOMEN: Soft. No masses.
GENITALIA: Normal penis. Testicles descended bilaterally.
RECTAL: Examination benign.
EXTREMITIES: No edema.

IMPRESSION: Right distal ureteral calculus.

PLAN: Right ureteroscopy, ureteral lithotripsy. Risks and complications discussed with the patient. He signed a true informed consent. No guarantees or warrantees were given.