Urology Case Study

CHART NOTE

Comes in today for exam because of vaginal and perineal burning and itching which began during the night.  When she urinates, she feels burning towards the perineum, but is not certain if it is specifically on it, in addition to a severe burning sensation when the urine hits her labia.  She is having no urinary frequency.

PHYSICAL EXAMINATION

Perineum is very sensitive at the introitus and the labia minora, which are erythematous without discrete lesion.  Palpation of the urethra is extremely painful.  Suprapubic palpation is nontender.

Spun clean-catch urinalysis shows a few wbc’s and a few rbc’s in a very dilute sample.  C&S is sent.

ASSESSMENT

Probable urethritis.

PLAN

Prescription for doxycycline 100 mg p.o. b.i.d. for 10 days is given.

FOOTNOTE

Line 14.  Exam was translated as Examination in the heading.

Line 15.  The comma dictated after introitus was deleted.

Line 19.  White blood cells and red blood cells are written in small caps and plural is written with apostrophe.

Urology

DISCHARGE SUMMARY

DISCHARGE DIAGNOSES

1. Left hydronephrosis.

2. Possible left ureteral obstruction.

3. Rule out horseshoe kidneys.

BRIEF HISTORY

A 61-year-old male who developed flank pain on the left side.  He has had intermittent episodes of left flank pain which have lasted about 24 hours.  There is no history of hematuria or renal calculi.  He developed a similar episode earlier this week which persisted for 72 hours, and repeat IVP demonstrated progression of the hydronephrosis on the left side.  He denied fevers, chills, or history of urinary tract infections.  He does have mild BPH as well, with some decrease in force of stream.

His past history is essentially negative other than a history of esophagitis.  He is on no medications.  Denied allergies or previous surgeries.

Physical examination was significant for grade 2/4 left flank and left lower abdominal tenderness.  Otherwise, physical examination was within normal limits.

HOSPITAL COURSE

The patient was admitted for pain control.  Serum creatinine was 1.7.  On the second hospital day, he underwent cystoscopy and left retrograde pyelogram which revealed a possible left ureteral stricture.  This was dilated.  There were no stones apparent, and a double-J stent was left in place.  Postoperatively the patient was pain-free.  Stent will be removed in about 1 month’s time.  His medications on discharge include Septra DS 1 b.i.d. and Vicodin.

FOOTNOTE

Line 15.  Are was changed to is for subject-verb agreement
(is ... history...).

Urology case study

DISCHARGE SUMMARY

DIAGNOSES

1. Radiation cystitis.

2. Carcinoma of prostate, stage D.

3. Left inguinal hernia.

OPERATIONS PERFORMED

Ileal conduit.  Left inguinal hernia repair.

HISTORY

This 60-year-old male with advanced carcinoma of the prostate, who had radiation therapy for this, was found to have severe contraction of the bladder from the radiation cystitis.  The patient has been incapacitated by this.  Also has had a painful left inguinal hernia.

After preop evaluation, patient was brought to surgery where an ileal conduit and left inguinal hernia repair were performed.  The patient tolerated the procedure well.  Estimated blood loss:  750 cc for the total procedure.

The patient was observed in intensive care for 2 days and then transferred to surgical floor.  The patient received 1 unit of packed cell blood replacement on the second postop day.  The patient had slight Jackson-Pratt drainage, and bowel sounds and flatus were noted.  The patient was fed, tolerated this well.  Foley catheter was removed.  Bladder was left intact, not removed; it was very tiny and scarred in.

Patient continued to improve over the next couple of days and was discharged home on Home Health followup.

FOOTNOTE

Line 9.  The slang term CA was changed to carcinoma.

Line 23.  Was performed was changed to were performed for subject-verb agreement (conduit and ... repair were).

Line 31.  And was deleted to shorten the run-on sentence.

Line 36.  Alternative:  Home Health (an organization) as opposed to home health (a service).  Since it is not clear which is meant, either is acceptable.

Urology Case Study

CHART NOTE

CHIEF COMPLAINT

Phimosis with adhesions.

This patient has been in my office several times over the past few months with adhesive bands due to the foreskin being adherent to the glans penis with secondary infection due to entrapment of smegma.  This has been freed up; however, it recurs.

Abdomen scaphoid, bowel sounds present, no masses, no scars.  External genitalia normal for the child’s age.  Uncircumcised male with adhesive bands on the foreskin.  Both testes descended.  No hernia.

DIAGNOSIS

Phimosis with adhesions.

FOOTNOTE

Line 13.  Reoccurs (not a word) was changed to recurs.

Urology Study

CHART NOTE

This is a 60-year-old male who states that he has had a problem of retracting the foreskin for some time; it is getting much worse.  He can retract it over the glans only with great difficulty and then it constricts around the penis at the base of the glans, causing it considerable discomfort.  He then has difficulty taking the foreskin back down over the glans.  He also noticed increasing secretions coming from the area.  He is desirous of having this problem corrected by circumcision.

IMPRESSION

Phimosis.

PLAN

The plan is for circumcision.

FOOTNOTE

Line 13.  The physician made a correction; reducing or was deleted.