Urology Consult - concise

Date: 2025-12-29  
Referring Physician: Dr. Carter

**CHIEF COMPLAINT:**  
Patient presents to the office today to discuss:  
1. Left flank pain  
2. Evaluation of renal cysts

**HPI TODAY:**  
Emily presents with intermittent aching pain on the left flank, corresponding to the location of the largest renal cyst, which has been present for approximately five to seven years. She describes the pain as sometimes resembling the sensation of a kidney stone forming, though she has not passed any stones recently. She denies current urinary or bladder symptoms, hematuria, or urinary tract infections. She has a history of kidney stones and underwent ureteroscopy in the past. She is currently taking hydrochlorothiazide for hypertension.  
Prenuvo MRI (July 4, 2025): Multiple bilateral renal cysts, largest 5.2 x 5.8 cm, consistent with benign simple cysts. Degenerative changes at multiple spinal levels and rightward scoliosis noted. I personally reviewed and independently interpreted the scan and agree with the findings.  
Renal ultrasound (August 16, 2025): Right kidney measures 11.3 cm with multiple cortical and parapelvic cysts, some with thin septations, largest 2.2 x 2.0 cm. Left kidney measures 11.6 cm with multiple cysts, largest with thin septations.  
Creatinine: 133 µmol/L. Estimated GFR: 56 mL/min/1.73m2. PSA: 4.3 (July 27, 2025). Urine culture: No growth (July 28, 2025). Prostate volume: 43.4 mL.

**PMH, PSH, MEDS, ALLERGIES, SH, and FH:**  
- Information reviewed with patient and in EMR, with changes made where appropriate.  
- Hypertension, hyperlipidemia, overweight, history of kidney stones, possible chronic kidney disease, peripheral neuropathy not yet diagnosed, tinnitus, spinal compression in the lumbar region, umbilical hernia, low vitamin D, cold sores.  
- Right total hip replacement in 2016 due to decompression sickness from diving. Ureteroscopy for kidney stones. Umbilical hernia identified but not repaired.  
- Hydrochlorothiazide 25 mg orally once daily.  
- Family history of cardiovascular disease and cancer. History of diabetes in a family member who died in the 1970s, prior to the recognition of any kidney, bladder, or prostate issues.

**ASSESSMENT AND PLAN:**  
Emily has multiple bilateral renal cysts, the largest measuring 5.2 x 5.8 cm on the left, with thin septations but no features concerning for malignancy. The cysts are consistent with benign simple cysts and are not considered pre-cancerous or likely to cause her pain. Her left flank pain is more likely attributable to degenerative changes in the lumbar spine, as noted on MRI. Renal function is mildly reduced but stable. She has an enlarged prostate without current lower urinary tract symptoms. No evidence of urinary tract infection or active nephrolithiasis.

1. Simple renal cysts, bilateral (N28.1)  
- Assessment: Multiple simple cysts in both kidneys, largest on the left. No evidence of malignancy or complex features. Symptoms are unlikely to be related to the cysts.  
- Plan: No surgical intervention or cyst aspiration recommended. No routine follow-up imaging required for simple cysts unless symptoms change.  
- Counseling: Cysts are not cancerous or pre-cancerous and rarely cause pain or infection. Surgery is not indicated as it would not improve symptoms.

2. Chronic kidney disease, stage 3a (N18.31)  
- Assessment: Mildly reduced GFR and elevated creatinine, stable.  
- Plan: Continue monitoring renal function and potassium periodically.

3. History of nephrolithiasis (N20.0)  
- Assessment: Prior kidney stones, status post ureteroscopy, no recent episodes.

4. Benign prostatic hyperplasia (N40.1)  
- Assessment: Enlarged prostate (43.4 mL) without current lower urinary tract symptoms.  
- Plan: No treatment indicated at this time. Monitor for development of symptoms.  
- Counseling: If urinary symptoms develop in the future, medical or surgical options are available.

5. Lumbar degenerative disc disease (M51.36)  
- Assessment: Degenerative changes at multiple spinal levels, likely source of back and flank pain.

6. Umbilical hernia (K42.9)  
- Assessment: Identified, not repaired, asymptomatic.  
- Plan: No intervention required unless symptoms develop.

**SHORT SUMMARY:**  
Emily was seen for evaluation of left flank pain and multiple renal cysts. Her symptoms are most likely related to lumbar degenerative changes rather than the renal cysts, which are benign and require no intervention.

Next appointment: As needed for symptom changes or routine follow-up.