Patient presents with [chief complaint related to hydronephrosis, e.g., flank pain, abdominal pain, urinary tract infection, hematuria].  Review of systems reveals [positive findings, e.g., nausea, vomiting, dysuria, frequency, urgency] and pertinent negatives include [negative findings].  Past medical history includes [relevant past medical history, e.g., kidney stones, nephrolithiasis, ureteropelvic junction obstruction, posterior urethral valves, vesicoureteral reflux, prostate enlargement, bladder outlet obstruction].  Family history is significant for [relevant family history, e.g., polycystic kidney disease].  Medications include [list medications].  Physical exam reveals [relevant findings, e.g., costovertebral angle tenderness, palpable abdominal mass].  Preliminary diagnosis of hydronephrosis is suspected.  Ordered renal ultrasound to evaluate for hydronephrosis severity, assess renal pelvis dilation, and identify any underlying obstructive uropathy.  Differential diagnoses include pyelonephritis, renal cyst, renal tumor, and other causes of urinary tract obstruction.  Will consider CT urogram if ultrasound is inconclusive.  Patient education provided regarding hydronephrosis symptoms, causes, treatment options including ureteral stenting or nephrostomy tube placement, and potential complications like kidney damage or infection.  Plan to discuss management based on imaging results and follow up in [timeframe] to reassess and adjust treatment as needed.  ICD-10 code N49.  CPT codes for potential procedures such as renal ultrasound 76770, CT urogram 74177, ureteral stent placement 50398, and nephrostomy tube placement 50392 may be applicable depending on the course of treatment.