What are the errors in this passsage: Report #3 Discharge Summary (5 errors in t
ID: 49306 • Letter: W
Question
What are the errors in this passsage:
Report #3 Discharge Summary (5 errors in this report)
Case History: This 32-year-old single white male, appearing his stated age, was admitted to the hospital after presenting to the emergency room in acute distress. He complained of intermittent pain in the right posterior lumbar area radiating to the right flank. He has a family history of pyelolithiasis and has been treated for this condition several times in the past ten years.
Discharge Summary: This patient was admitted to the endocrinology unit from the emergency room, complaining of severe intermittent pain the back and right flank. His KUB showed one calculi in the region of the right renal pelvis. Laboratory data were all normal except for slight microscopic hematuria. An intravenous pyelogram showed three stones in the right gallbladder with minimal hydronephrosis. A right retrograde pyelogram confirmed presence of three stones in the left kidney. Minimal ureteral obstruction was present. Incision into the renal pelvis was completed with no complication. A ureteral catheter was inserted as was an indwelling Foley catheter. Drainage from the right kidney was pale yellow in forty-eight hours. These catheters were removed three days postoperatively. At discharge, the patient is voiding without difficulty, is febrile with a temperature of 98.6°, and ambulatory. The stones were sent to the laboratory for analysis. The report indicated that they were composed of calcium. He is discharged to his home on restricted activity for the next two weeks. He is advised to drink a large amount of fluid. He will be followed in the office in three weeks.
Explanation / Answer
He complained of intermittent pain in the right posterior
lumbar area, radiating to the right flank. He has a family history of nephrolithiasis and
has been treated for this condition two other times in the past ten years.
This patient was admitted to the Urology Unit and was administered intravenous
morphine sulfate for pain control. VITAL SIGNS: Low-grade temperature of 99.4.
Initial blood pressure was 146/92.
The white blood count, hemoglobin, and hematocrit normal.
The urinalysis showed microscopic hematuria.
A KUB revealed calculi in the region of the right renal pelvis. A cystoscopy with a
right retrograde urogram confirmed the presence of the three stones in the right
kidney. Minimal ureteral obstruction was present.
A percutaneous nephropyelolithotomy was completed with no complications. A
ureteral stent was inserted as was an indwelling Foley catheter. Drainage from the
right kidney was pale yellow in 48 hours. The Foley catheter was removed three
days postoperatively.
At discharge, the patient is voiding without difficulty. The stones were sent to the
laboratory for analysis. The report indicated that they were calcium oxalate.
The patient is to follow up with his urologist in a week to have his ureteral stent
removed.
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