| Physical Exam |
05/27/XX |
48 year old male with L upper quadrant pain for a month. Had abnormal CT, IVP, renal nuclear scan at outside facility. |
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| X-Rays & Scans |
05/19/XX |
CXR normal. |
| 05/20/XX |
CT showed large L hydronephrosis and UP junction obstruction. No lymphadenopathy. |
| 05/27/XX |
Retrograde cystoscopy: anterior urethra WNL. Prostatic urethra showed mild BPH. Bladder negative. L retrograde ureteropyelogram revealed non-functioning L kidney with ureteropelvic junction obstruction, markedly dilated L pyelocaliceal system, longstanding hydronephrosis. |
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| Operative Findings |
05/28/XX |
Extensive inflammation of left kidney parenchyma, kidney huge and grapefruit sized. No complications during procedure. |
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| Pathological Reports |
05/28/XX |
L kidney nephrectomy: high grade papillary urothelial carcinoma of renal pelvis w/extension through muscularis propria into peripelvic adipose tissue. Ureter margin negative. Negative involvement of adrenal, renal vein and artery. No lymph nodes identified. |
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| Treatment |
05/28/XX |
Surgery: Left nephroadrenalectomy. |
| 07/11/XX |
Radiation: Began beam radiation 3000 cGy treatment of renal bed. |
| 07/28/XX |
Chemotherapy: Began Chemo – Gemzar, carboplatin. |
