Urology Office Consultation Question & Answer Guide (With Explanation)

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Key Explanation

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Original Question

Urology Office Consultation REASON FOR REFERRAL Right flank mass, hematuria. HISTORY OF PRESENT ILLNESS The patient noticed the onset of hematuria following a motorcycle accident 1 week prior to admission. The patient denies dysuria or abdominal pain or distention and did not seek medical care for his symptoms until today. PAST HISTORY Medications: None. Illnesses: None. Operations: Tonsillectomy and adenoidectomy at age 8 years. ALLERGIES: ALLERGIC TO IODINE AND SHELLFISH. REVIEW OF SYSTEMS Noncontributory. PHYSICAL EXAMINATION GENERAL: The patient is a well-developed 26-year-old Caucasian male in no acute distress who is oriented and cooperative. VITAL SIGNS: Pulse: 80/min. Blood pressure: 116/82. Respiratory rate: 20/min. HEENT: PERRLA. EOMs intact. Funduscopic examination shows no capillary aneurysms, hemorrhages or exudates. NECK: Supple without adenopathy. CHEST: Lungs: Clear to auscultation and percussion. Heart: RRR. S1 and S2 present. No murmurs, bruits or rubs. ABDOMEN: Very tender right CVA. There is a 15 cm palpable mass in the right upper quadrant and periumbilical region. The mass is freely moveable. Bowel sounds are normal. No evidence of hernia. Liver and spleen normal. RECTAL: Deferred. EXTREMITIES: Normal. No clubbing, cyanosis or edema. No ulcers or trophic changes. NEUROLOGIC: Deferred. DATABASE Abdominal sonography reveals a 15 cm mass in the midpole of the right kidney with irregular texture and contour. No discrete fluid collections are seen. An IVP was deferred in view of the patient’s history of iodine allergy. BUN 15, creatinine 23. Urinalysis shows microscopic hematuria, proteinuria and 10-15 WBC. Specific gravity 1.020. ASSESSMENT Right nephroma. Rule out renal cell carcinoma, subcapsular or intrarenal hematoma, or focal xanthogranulomatous pyelonephritis. RECOMMENDATIONS The patient’s history of trauma is probably unrelated to the mass in the kidney, due to the minor amount of discomfort the patient experienced and the abnormal accompanying laboratory values. It is most likely that this is an incidental finding and due to renal cell carcinoma or adenocarcinoma of the kidney. Renal biopsy is recommended. ICD-10-CM needed & E/M: NEEDED

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