Urologist called to see patient for renal stone.. patient has a high number of comorbidities so provider decides patient is not a candidate for treatment of the stone. This patient's problems are addressed, but due to the high risk, treatment is considered and ultimately decided against. How would you level this medical decision making?
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate male with multiple medical problems including metastatic pancreatic cancer with metastases to his lungs, who underwent recent CT that showed nonobstructing right calyceal calculus. The patient has multiple medical problems including hypertension, diabetes, peripheral neuropathy, PE on Eliquis, history of coronary artery disease, sleep apnea, hypothyroidism, chronic pain syndrome, narcotic dependence, respiratory distress, metastatic pancreatic cancer including lung metastases and malignant ascites requiring thoracentesis and paracentesis, who had a CAT scan performed showing an obstructing calyceal stone. The patient apparently had undergone endoscopic removal of a renal calculus in the distant past where he claimed he almost died postoperatively. He claims he has some mild intermittent lower back pain, but no actual flank pain.
PAST MEDICAL HISTORY: Dictated above.
MEDICATIONS: Listed in the chart.
REVIEW OF SYSTEMS: Negative except as stated above.
PHYSICAL EXAMINATION:
GENERAL: He is an obese male, lying in bed, on oxygen.
VITAL SIGNS: Stable.
HEENT: Grossly normal.
LUNGS: Decreased breath sounds bilaterally.
ABDOMEN: Benign, nontender. No CVA tenderness.
NEUROLOGICAL: Grossly normal.
IMPRESSION: 1. Right calyceal calculi with calyceal obstruction, but no hydronephrosis. 2. Multiple medical issues including end-stage pancreatic cancer.
PLAN: The patient is not a candidate for any urological operative intervention for his calyceal stones.
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate male with multiple medical problems including metastatic pancreatic cancer with metastases to his lungs, who underwent recent CT that showed nonobstructing right calyceal calculus. The patient has multiple medical problems including hypertension, diabetes, peripheral neuropathy, PE on Eliquis, history of coronary artery disease, sleep apnea, hypothyroidism, chronic pain syndrome, narcotic dependence, respiratory distress, metastatic pancreatic cancer including lung metastases and malignant ascites requiring thoracentesis and paracentesis, who had a CAT scan performed showing an obstructing calyceal stone. The patient apparently had undergone endoscopic removal of a renal calculus in the distant past where he claimed he almost died postoperatively. He claims he has some mild intermittent lower back pain, but no actual flank pain.
PAST MEDICAL HISTORY: Dictated above.
MEDICATIONS: Listed in the chart.
REVIEW OF SYSTEMS: Negative except as stated above.
PHYSICAL EXAMINATION:
GENERAL: He is an obese male, lying in bed, on oxygen.
VITAL SIGNS: Stable.
HEENT: Grossly normal.
LUNGS: Decreased breath sounds bilaterally.
ABDOMEN: Benign, nontender. No CVA tenderness.
NEUROLOGICAL: Grossly normal.
IMPRESSION: 1. Right calyceal calculi with calyceal obstruction, but no hydronephrosis. 2. Multiple medical issues including end-stage pancreatic cancer.
PLAN: The patient is not a candidate for any urological operative intervention for his calyceal stones.
