Patient: [Patient Name]
Date: [Date of Encounter]
I. Diagnosis:
Age at diagnosis of congenital hydronephrosis
Affected kidney(s) (unilateral or bilateral)
Severity (mild, moderate, severe) – based on degree of dilation and functional impairment
II. Past Medical History:
Prenatal history (antenatal ultrasound findings suggestive of hydronephrosis)
Urinary tract infections (UTIs) (frequency)
Previous surgeries for hydronephrosis (pyeloplasty, ureteral reimplantation)
III. History of Present Illness:
Reason for this visit (routine follow-up, new symptoms)
Current symptoms (select all that apply):
Abdominal pain (flank pain)
Urinary tract infection (UTI) symptoms (dysuria, urgency, frequency)
Gross hematuria (blood in urine)
Hypertension (may occur in severe cases)
Growth concerns (if affecting kidney function)
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Abdominal exam: (abdominal mass on affected side if severe)
Urinalysis (may show signs of infection or hematuria)
V. Imaging Studies (if available):
Ultrasound: (initial evaluation, assess degree of dilation)
Renal scan (MAG3 scan or DMSA scan): (evaluate kidney function and drainage)
Voiding cystourethrogram (VCUG): (assess for anatomical abnormalities)
Other imaging studies (MRI, CT scan) – if needed for complex cases
VI. Assessment:
Current status of hydronephrosis (stable, worsening)
Kidney function (preserved or impaired)
Risk of complications (urinary tract infections, kidney damage)
VII. Plan:
Management plan depends on severity and progression:
Observation (serial ultrasounds to monitor) – for mild cases with stable function
Surgical intervention (pyeloplasty, ureteral reimplantation) – for moderate or severe cases, or if worsening
Antibiotic prophylaxis (to prevent UTIs) – if recurrent infections
Blood pressure management (if hypertension present)
Follow-up schedule (urinalysis, imaging studies)
Referral (if indicated):
Pediatric urologist for surgical management or complex cases.
VIII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the condition, adherence to recommendations, and potential for long-term complications.
IX. Resources:
Consider providing patient education materials on congenital hydronephrosis from reputable sources (e.g., National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), American Urological Association (AUA)).