Urogynecology & Minimally Invasive Surgery – New Consult

Dear [referring_physician_name],

Thank you for referring Julia Fairchild, a female referred for follow-up of nephrolithiasis and pregnancy-related symptoms.

HISTORY OF PRESENT ILLNESS:
Julia Fairchild presents with a longstanding prominence of the right pelvic calyceal system since February 2024, with no prior history of nephrolithiasis before this pregnancy. She has a history of recurrent urinary tract infections and previous episodes of pyelonephritis. She underwent an ultrasound in February 2024 that demonstrated right-sided renal enlargement compared to the left. A recent ultrasound performed four weeks ago demonstrated no change in the appearance of right-sided hydronephrosis and persistent hyperechogenicity in the lower pole of the right kidney, consistent with a renal calculus. Over the past week, she has experienced significant dysuria, burning, pruritus, and right-sided flank pain. She reports a recent episode of urinary tract infection, for which she completed a course of amoxicillin a couple of weeks ago, and previously received cephalexin with good symptomatic improvement. Recent laboratory investigations demonstrated pyuria and nitrite positivity. She is currently pregnant, with an estimated due date of February 9. She denies any additional questions or concerns at this time.

PELVIC FLOOR INVENTORY:
• Prolapse symptoms: none
• Stress incontinence: none
• Lower urinary tract symptoms: yes
• Voiding dysfunction: none
• Defecatory dysfunction: none
• Sexual dysfunction: none

PREVIOUS PELVIC FLOOR MANAGEMENT:
• Pessary: none
• Pelvic floor physiotherapy: none
• Overactive bladder medication: none
• Pelvic floor surgery: none

OBSTETRIC & GYNECOLOGIC HISTORY:
• Gravida/Para/Term/Abortions/Living (G P T A L): [details]
• Vaginal deliveries: [number]
• Cesarean sections: [number]
• Menopausal status: [details]
• Sexual activity: [yes/no]
• Hormone therapy/Contraception: [details]

PAST MEDICAL HISTORY:
• Recurrent urinary tract infections
• Previous episodes of pyelonephritis
• No prior history of nephrolithiasis before current pregnancy

PAST SURGICAL HISTORY:
• [List of surgical procedures with dates and outcomes]

FAMILY HISTORY:
• [Details of significant family medical history or none]

SOCIAL HISTORY:
• [Details of tobacco, alcohol, drug use, occupation, living situation, marital status, or none]

MEDICATIONS:
• Amoxicillin (recently completed course)
• Cephalexin (previously received with good symptomatic improvement)

ALLERGIES:
• [List of allergies and reactions or NKDA]

PHYSICAL EXAM:
• General: Appears well, alert, and in no acute distress
• Abdomen: No specific findings documented
• Pelvic exam (with split speculum): [details of findings including vulva, vaginal epithelium, prolapse stage, urethral hypermobility, genital hiatus, perineum support, muscle strength, levator ani tone, bimanual exam, and POP-Q measurements]

IMPRESSION & SUMMARY:
Julia Fairchild is a female with the following problems:
1. Nephrolithiasis (renal calculus, right kidney)
2. Right-sided hydronephrosis
3. Pregnancy

MANAGEMENT PLAN:
During the consultation, both conservative and surgical management options were reviewed. The next steps are as follows:
1. Prescribed cephalexin again for urinary tract infection
2. Advised to call if she has concerns or if symptoms worsen
3. Return in two weeks for a group B streptococcus swab and further assessment

It is a pleasure to be involved in the care of this patient.

Sincerely,

David Mensah, Obstetrics & Gynecology (ObGyn)
Regional Womens Health Clinic