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CLINICAL EXAMPLE 99251
 

 
Patient with urinary retention following laparoscopic cholecystectomy

Reason for consultation : Post-op urinary retention

Requesting clinician : Jane Doe, MD

HPI : The patient is a 41 year old male who underwent uncomplicated laparoscopic cholecystectomy earlier today and has had trouble voiding.  He complains of some mild colicky midline abdominal discomfort.

Physical Exam

Abdomen: Soft and nontender with positive bowel sounds and no masses
GU: normal external genitalia
Bladder scan showed 400 cc of urine in the bladder

Assessment

1. Transient post anesthesia urinary retention

Plan
  1. Insert Foley catheter
  2. Can likely remove catheter this evening
  3. Will re-evaluate if problem persists after 24 hours


For a detailed breakdown of this note with tips and advice see  99251 E/M Insight

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