Urology Case Study

CHART NOTE

Patient is a 62-year-old white male with bladder outlet obstructive symptoms.  These include hesitancy, a decrease in the force and strength of urinary stream, nocturia x0 to 3, urgency with some mild urge incontinence.  Patient also makes note of terminal dribbling.  Denies any stopping and starting of stream once stream has been established.

An intravenous pyelogram was performed, which showed a prostatic enlargement with elevation of the bladder floor and a 2-cm right renal mass.  Ultrasonography was performed, which showed the questionable renal mass as being a complex renal cyst, but this was followed up with a CT scan which showed the cyst to be simple in its complexity.  No tumor was noted.

Physical examination in the office revealed the prostate to be smooth, benign, approximately 60 g in weight.  Followup cystoscopy revealed trilobar hypertrophy with severe prostatic varices.  A followup cystogram was performed, which revealed a moderate postvoid residual with a left-sided bladder diverticulum.

IMPRESSION

1. Benign prostatic hypertrophy with bladder outlet obstruction.

2. Left-sided bladder diverticulum.

PLAN

The patient is to be scheduled for an elective TURP under anesthesia.  The possible complications including but not limited to death, have been explained to the patient.  He claims he understands and accepts.  He will donate 2 units of autologous blood prior to the procedure since he does not wish to receive blood bank blood in case transfusion should be indicated.

FOOTNOTE

Line 9.  Alternative:  0-3.

Line 11.  Starting or stopping was changed to stopping and starting to convey the correct meaning.  (Once the patient’s stream has been established, it has already started.)

Lines 17, 18.  CT was then followed was changed to ... this was followed up with a CT scan which showed ... for clarity.

Line 24.  Varicoces was changed to the correct term varies.

Line 29.  BPH was translated in the Impression for clarity.