Urology Studies

HISTORY AND PHYSICAL EXAMINATION

Patient is an 81-year-old male.  The patient has a history of blood in the urine and has had trouble urinating and infections in the urinary tract.  The patient has nocturia twice per night with a slow urinary stream and back pains.  An IVP done, March 1, 1988, showed a distended urinary bladder with a large postvoid residual.  Upper tracts were unremarkable except for some cortical scarring and small cortical renal cysts.  Cystoscopy was performed, which revealed a deep diverticulum of the bladder with inflammatory or neoplastic lesion within the diverticulum.  This area was biopsied, and biopsy showed ulceration and chronic inflammation of the bladder but no malignancy.  The patient may have a stone beneath this area, but we cannot tell that well under the local anesthesia.  The patient had obstructive BPH with a large residual urine.  A TURP is recommended.  Patient may need open resection of the bladder diverticulum if any tumor is found at the time of TUR.  The plan is to do a transurethral resection of the prostate and further biopsies and TUR of this lesion of the diverticulum, but not to dissect anything deeply in the diverticulum for fear of rupturing the diverticulum.  The patient is aware of this and the risks, complications, and alternatives and the possibility of requiring open surgery or drainage.  The patient is agreeable with this and is admitted to the hospital for the above-mentioned procedure.

PAST MEDICAL HISTORY

Past medical history is that of mild heart attack, hip replacement, herniorrhaphy.

ALLERGIES

None.

MEDICATION

Bactrim, Pyridium, cephalexin, Theo-Dur, arthritis medications, and aspirin.

REVIEW OF SYSTEMS

Weight loss, ear problems, constipation, back pains, joint pains.

SOCIAL HISTORY

Married.  Retired.  5 children.  Does not smoke; quit about
12 years ago.  Drinks alcohol, 1 cup of wine at dinner.

FAMILY HISTORY

Family history of cancer and arthritis.

PHYSICAL EXAMINATION

GENERAL:  Physical examination reveals a well-nourished male in no acute distress.

HEENT:  Pupils equal, round, and react.  Ears, nose, and throat clear.

NECK: Supple.  No JV distention or bruit.

LUNGS:  Clear to P&A.

HEART:  Regular rhythm, no murmur.

ABDOMEN:  Soft, nontender.  Well-healed inguinal herniorrhaphy scar and hip scar.

EXTREMITIES:  Without cyanosis, clubbing, or edema.

NEUROLOGICAL:  Oriented x3 with no gross deficit.

IMPRESSION

1. Benign prostatic hypertrophy.

2. Possible bladder tumor or stone within bladder diverticulum.

RECOMMENDATION

TUR of prostate and further biopsies of bladder lesion.  Possible open diverticulectomy and tumor resection.

FOOTNOTE

Line 25 (Page 1).  The slang term tic was translated diverticulum.

Line 32 (Page 1).  The redundant phrase heart attack was deleted.

Line 39 (Page 1).  Meds was translated as medication.

Line 2 (Page 2).  Exam was expanded to Examination in the report.

Line 3 (Page 2).  The subheading General was added for clarity.

Line 5 (Page 2).  The subheading HEENT was added for clarity.

Line 16 (Page 2).  BPH was expanded in the Impression for clarity.