DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Urology opinion regarding gross hematuria.
CHIEF COMPLAINT: Blood in the urine.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic male known to us, who has a history of radiation cystitis. The patient, unfortunately, recently had a myocardial infarction and had stents placed, which necessitated his being placed on Plavix and aspirin. He had begun hyperbaric oxygen therapy for his radiation cystitis and had actually begun having some improvement. Then, after being placed on the blood thinners, he had some issues with recurrent gross hematuria.
Since that time, the patient has actually needed blood transfusions and has recently been admitted with the need for a blood transfusion on this visit. He has had a few clots in his urine but no clot retention. The duration of these events has been since being placed on the Plavix. The timing of the hematuria is random; it is not seemingly made worse or better by anything. He does not have any associated bone pain, night sweats, weight loss, fevers or chills. He is not having any real changes in lower urinary tract symptoms.
Past medical history, past surgical history, allergies, social history, and family history are reviewed and unchanged with the addition of his heart attack and stent placement.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is afebrile with stable vital signs.
GENERAL: The patient is awake, alert, and oriented x4, in no apparent distress, appears well developed and well nourished, appears his stated age.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Sclerae anicteric. Extraocular movements are intact. Cranial nerves II-XII are grossly intact.
NECK: Supple. Thyroid unremarkable.
HEART: S1, S2. No obvious peripheral edema.
LYMPHATIC: The patient has no obvious lymphadenopathy, either supraclavicular or axillary.
LUNGS: Clear to auscultation bilaterally. No rales, wheezes or crackles. Equal excursion bilaterally with breathing.
ABDOMEN: Soft, nontender, and nondistended. His bladder is not palpable above the pubic symphysis. No CVA tenderness to percussion bilaterally. We do not appreciate any obvious hepatosplenomegaly. Bowel sounds are present in all four quadrants.
EXTREMITIES: No clubbing, cyanosis or edema.
GU: The patient’s testicles are descended bilaterally with no masses. Phallus is normal in appearance with orthotopic meatus. It does have a penile prosthesis that is deflated. There is also a pump in his scrotum. The patient’s urine is observed, and it appears pink with no obvious clots.
LABORATORY DATA: Labs are all reviewed. Of note, the patient is anemic and has a normal creatinine.
ASSESSMENT: The patient is a pleasant (XX)-year-old gentleman with radiation cystitis, gross hematuria, anemia, status post prostatectomy with a history of lower urinary tract symptoms.
PLAN: At this point, the patient is not in clot retention and does not need any intervention for this. As far as the patient’s radiation cystitis is concerned, we talked to the patient about the following options along with their concomitant risks and benefits; observation, supportive therapy for his other issues until he can get back into hyperbaric oxygen therapy for hopeful treatment of this issue, beginning an Amicar irrigation of his bladder, systemic Amicar, instillation under anesthesia of silver nitrate, instillation under anesthesia of formalin, instillation under anesthesia of alum.
After discussing all these issues and their side effects and benefits, the patient has decided to try to treat this conservatively, and therefore, we will watch his blood counts. If after the transfusions his hematocrit comes up to a reasonable level and stays there, we believe that it is very reasonable to try to temporize this until he can get more hyperbaric oxygen therapy underway in hopes of decreasing his hematuria. He understands that should this not be a stable situation, we may be forced to do something more invasive, such as instillation of formalin. The patient is not interested in Amicar instillation at this point either; although, we think that would probably be the next most reasonable step.
With regard to anemia, we believe that the patient should be ruled out for other sources of blood loss. We spoke with his primary team about this at length, including at the very least stool guaiacs, if not being scheduled for a colonoscopy. We are ordering a CT scan to rule out issues with his upper tract as he has not had one in the recent past. Our plan is to follow the patient along while he is in the hospital and we will take it one step at a time conservatively. At the conclusion of the visit, the patient states that all his questions have been answered. He participated fully in the medical decision-making process.
