Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, Nephrolithiasis, Ureteral stent insertion, Ureterolithiasis, Ureteroscopy abnormal
Clinical narrative: Date of Admission: 12/3/2023     Date of Discharge: 12/04/2023   Issues to be Addressed at Follow-up: Stone treatment    Pending Study Results at Discharge: none   Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) HYPERTENSIVE URGENCY       12/11/2023 MD  Diagnosed with hypertensive urgency at ER on 12/3. Hospitalized for kidney stone.  Started on lisinopril 20 mg daily.   Has been checking BP at home and it is 122/80.  110/70.  Today 123/78.   Was started on lisinopril 20 mg daily.   Had potassium of 3.4.  Plans to repeat the lab later this week.  Recommend continue lisinopril 20 mg daily Plan to recheck bp's daily and plan to review again in a few weeks She will watch for dizziness or SBP less than 100.  May need reduced or stopped medication at that time.      ? URETERAL CALCULUS       12/11/2023 MD   Hospitalized 12/3 to 12/4 Presented to Emergency Department with abdominal pain, nausea, vomiting and left obstructed kidney stone (5 mm in distal left ureter with moderate left hydronephrosis)  and hypertensive urgency.  She had a stent placed and was observed and discharged.  No discharge summary available but progress notes reviewed.  Ureteroscopy to be scheduled.  Pt reports pain is pretty well controlled and has not had to take any medication for pain (has oxycodone 5 mg tablets but not needing them).  Still taking tamsulosin.  Surgery with Dr. scheduled for 12/21/2023.        ? COVID-19 DISEASE   ? ELEVATED BP READING WO HTN DIAGNOSIS     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 49 Y female  w/ ureteral stone. Presented for  Procedure(s): URETERAL STENT PLACEMENT. Patient tolerated the procedure well, please see operative note for full details. Patient had an uncomplicated hospital course. Patient's diet was advanced as tolerated, he was ambulating, and pain was controlled.  Was d/c home on POD #1.     Primary Procedures:  Procedure(s): URETERAL STENT PLACEMENT   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Ureteral stone    Complications: none   Consults:  None   Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code       Note Details  Author  (M.D.) File Time 12/12/2023  5:41 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Urology Hospital Acct #  Admit Date 12/3/2023  ED to Hosp-Admission (Discharged) on 12/3/2023  ED to Hosp-Admission (Discharged) on 12/3/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Linked Episodes  URETERAL STENT PLACEMENT From 12/3/2023 to 12/4/2023 URETEROSCOPY RIGID W LAS Noted 12/3/2023  Hospital Problem List   HYPERTENSIVE URGENCY  ELEVATED BP READING WO HTN DIAGNOSIS  URETERAL CALCULUS  COVID-19 DISEASE Care Timeline  12/03   URETERAL STENT PLACEMENT 12/04   Discharged 1430  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/4/2023)   Discharge Orders  BICARBONATE  BUN  CHLORIDE  CREATININE W GFR, CALCULATED  GLUCOSE  POTASSIUM  SODIUM  URINALYSIS W REFLEX TO MICROSCOPY PANEL Medication List at Discharge   acetaminophen 500 mg Take 1 to 2 tablets by mouth every 6 hours as needed for pain or fever. Do not exceed 6 tablets in 24 hours  lisinopril 20 mg Oral DAILY  ondansetron HCl 4 mg Take 1 tablet by mouth every 8 to 12 hours as needed for nausea or vomiting  oxycodone HCl 5 mg Oral EVERY 6 HOURS AS NEEDED  sennosides 8.6 mg Take 2 tablets by mouth daily as needed for constipation. May increase up to 4 tablets by mouth 2 times a day as needed for severe constipation. Do not exceed 8 tablets in 24 hours  tamsulosin HCl 0.4 mg Oral EVERY BEDTIME