Sample Reports

Urology . . . Page 1

These reports are samples of basic clinical evaluations of patients seen by a urologist. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.

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Edited Sample Report

The patient was seen in consultation on ******* He is a pleasant 2-year-old male who was seen regarding recurrence of balanitis and significant phimosis. He has had an inability to retract the foreskin.

Past medical history includes a benign heart murmur.

Physical examination revealed a 2-year-old male in no acute distress. Head and neck and chest are clear. Abdominal exam revealed no masses, no tenderness and no organomegaly. Genitalia exam shows a significant phimosis.

To recap, ******* is a 2-year-old male with significant phimosis and his parents wish him to have a circumcision as a permanent treatment and this will be arranged.

Edited Sample Report

Thank you for asking me to see this pleasant 78-year-old male who was seen regarding difficulty with urination. He has had a previous TUPR in May of 1997. He has difficulty in initiating his urination, especially in the morning. He has nocturia x 2-4. He thinks he empties completely. There is no dysuria, no hematuria.

Past medical history includes hypertension. Allergies nil. Medication includes Zestril.

Physical examination revealed a 78-year-old male in no acute distress. Head and neck and chest are clear. Abdominal exam revealed no masses, no tenderness and no organomegaly. Genitalia were normal. DRE shows a fairly small prostate from previous TUPR.

To recap, Mr. ******* is a 78-year-old male with some increasing obstructive symptoms following a TUPR 1 years ago. The differential diagnosis would include urethral stenosis or a bladder neck contracture. I will arrange for a cystoscopy for definitive diagnosis and then he will be seen for further management.

Edited Sample Report

I have seen ******* in a follow-up visit on *******

Prostatic biopsy showed no evidence of any prostatic carcinoma. The elevated PSA and digital rectal exam were likely secondary to nodular BPH. He will, therefore, be followed up conservatively. I would recommend a PSA in six months' time.

If his PSA remains stable, he will be followed up conservatively. If there is further elevation, then he should be reassessed.

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