UROPATHY PT

Situation:

56-year-old female with abdominal and lefts flank pain x1 day, dysuria, and known history of kidney stones. Imaging revealed a partially obstructing left renal stone with concern for UTI. CT also shows large stool burden with possible focal colitis, without obstruction or diverticulitis. Currently 

A&O×4, on room air, NPO, and receiving NS at 75 mL/hr.

B – Background:
PMH: Endometriosis, anemia, neuropathy, HTN, chronic constipation/IBS, GERD, kidney stones.
Home meds include: Toprol (HTN), Protonix (GERD), gabapentin (neuropathy).
Symptoms began 1 day ago. Care plans reviewed.

A – Assessment:

• Obstructive uropathy secondary to left renal stone, possible associated UTI.

• Large stool burden consistent with chronic constipation; focal colitis possible on CT.

• No bowel obstruction noted.

• Patient hemodynamically stable, pain ongoing but controlled with medication.

R – Recommendation:

• Maintain NPO status

• Continue ceftriaxone, IV fluids, pain and nausea management

• Consult IR for possible PCNT (Percutaneous Nephrostomy Tube, 

• Resume bowel regimen once eating; consider PRN enema

• Continue home meds (Toprol, Protonix, gabapentin)

• Arrange outpatient urology follow-up

Brief Progress Note

Principal Problems:

• Obstructive uropathy / left renal stone

• Severe constipation / large stool burden

• HTN, GERD, neuropathy (chronic)

Plan:
1. Left renal stone with obstructive uropathy

• NPO

• Continue ceftriaxone

• IR consult for possible PCNT

• Oxycodone for pain, Zofran for nausea

• Outpatient urology follow-up

2. Large stool burden / chronic constipation / hx IBS

• Resume bowel regimen when diet restarted

• PRN enema if no relief

3. HTN

• Continue Toprol

4. GERD

• Continue Protonix

5. Neuropathy

• Continue gabapentin

Status: A&O×4, room air, NPO, NS at 75 mL/hr.