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.