ADMITTING DIAGNOSIS
His
admitting diagnosis is obstructive voiding symptoms with urethral stricture and
possible prostatism.
BRIEF HISTORY
An
80-year-old patient who was originally seen in early September with complaints
of obstructive voiding symptoms. He has
nocturia x10 at night. Complains of a
slow urinary stream with occasional dysuria and hesitancy as well. He denies any previous history of urinary
tract difficulties except for complaints of a right scrotal swelling. Cystoscopy was performed and revealed a
urethral stricture in the proximal portion of the anterior urethra. The cystoscope could not be advanced further
than this.
PAST MEDICAL HISTORY
His
past medical history is significant for hypertension, which is apparently mild
and untreated. There is a question of
peptic ulcer disease in the past as well.
Additional urologic history is that he has had previous urethral
sounding in the past for unknown urologic problems. Patient denies significant cardiac problems
and apparently has some mild chronic obstructive pulmonary disease as well.
MEDICATIONS
None.
ALLERGIES
He
denies allergies.
REVIEW OF SYSTEMS
Review
of systems is significant for some loss of appetite, hearing and vision
problems, and degenerative arthritis as well
SOCIAL HISTORY
He
is married, retired, has 2 children.
Does not smoke or drink.
PHYSICAL EXAMINATION
GENERAL: His physical examination reveals an elderly
male in no acute distress.
VITAL
SIGNS: His blood pressure was
150/88. His heart rate was 80.
HEENT: HEENT examination revealed pupils equal,
round, and reactive.
NECK: His neck was supple.
LUNGS: His lungs were clear to auscultation without
rales.
CARDIAC: His cardiac examination revealed a regular
rate and rhythm without gallops.
ABDOMEN: His abdomen was soft and nontender.
GENITOURINARY: GU examination revealed normal penis. His testes were both descended. There was a probable right spermatocele
present superior to the testis.
RECTAL: His rectal examination revealed a 20-g,
non-nodular prostate.
EXTREMITIES: Extremities were without edema.
IMPRESSION
The
overall impression is urethral stricture disease.
PLAN
The
plan is for direct-vision internal urethrotomy.
At the time of the procedure, his prostate will be assessed for
obstruction, and if obstructing, a TURP will be performed as well. These plans have been discussed in detail with
the patient. He understands and agrees
to proceed.
FOOTNOTE
Line
12 (Page 1). The article An was inserted
to avoid beginning the sentence with a numeral.
Lines
44 (Page 1)-11 (Page 2). Some headings
and subheadings were added.
Line
6 (Page 2). GU was translated in the
subheading.
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