Audio_Uro_Hp_13

HISTORY: The patient is a 68-year-old Spanish woman, who was found on physical examination to have a right upper quadrant abdominal mass. The patient does not have any symptoms. She was sent for a sonogram, which showed an 11-cm right renal cyst.

PAST MEDICAL HISTORY: Glaucoma.

PAST SURGICAL HISTORY: Partial thyroidectomy.

MEDICATIONS: Eye drops.

SOCIAL HISTORY: She is a non-smoker.

ALLERGIES: None.

FAMILY HISTORY: None.

REVIEW OF SYSTEMS: Otherwise negative.

LABORATORY DATA: BUN 16, creatinine 0.9. Urinalysis 1+ leukocyte esterase.

PHYSICAL EXAMINATION: The patient was alert, awake and oriented. There was no CVA tenderness. The abdomen was soft. Right upper quadrant fullness was palpated. The bladder and the left kidney were not palpable. There was no inguinal adenopathy or inguinal hernia.

The ultrasound films were not available for review.

IMPRESSION AND PLAN: I discussed the different options with the patient, such as watchful waiting, drainage of the cyst by interventional radiology or through a laparoscopic procedure. Prior to making a decision, she will undergo first a CT scan of the abdomen and pelvis without and with IV contrast and bring the film in to the office for review. She will be followed up after her CT scan.