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...).