Patient presents with [symptoms such as flank pain, abdominal pain, urinary tract infection, hematuria, or asymptomatic presentation].  Physical examination reveals [relevant findings such as costovertebral angle tenderness or palpable abdominal mass; otherwise, document "unremarkable"].  The patient's medical history includes [mention relevant comorbidities such as nephrolithiasis, ureteropelvic junction obstruction, bladder outlet obstruction, retroperitoneal fibrosis, or pregnancy].  Imaging studies, including [specify type of imaging such as ultrasound, CT urogram, MRI, or intravenous pyelogram], demonstrate dilatation of the ureter, consistent with hydroureter.  Differential diagnosis includes [mention relevant differentials such as ureteral stricture, extrinsic compression, or congenital anomalies].  Assessment: Hydroureter, [right or left, bilateral], likely secondary to [state suspected etiology, e.g., obstructing stone, UPJ obstruction].  Plan:  [Outline treatment plan. This may include observation, further diagnostic testing such as urine culture and sensitivity, renal function tests, or consultation with urology.  If intervention is planned, specify the approach, such as ureteral stent placement, nephrostomy tube placement, or surgical intervention]. Patient education provided regarding hydroureter, its potential causes, and the planned management. Follow-up scheduled for [specify timeframe] to reassess symptoms and monitor the hydroureter. Coding considerations include ICD-10 code [N13.4 for unilateral hydroureter, or N13.5 for bilateral hydroureter] and appropriate CPT codes for procedures performed.