Sample Reports

Edited Sample Report

Thank you for referring this patient and thank you for the accompanying information. The patient was seen in consultation on******* She is a pleasant 42-year-old female that was investigated by ultrasound for some abdominal symptoms at which time it was discovered that she had a nonfunctioning kidney with a cyst associated with it, but also the possibility of solid lesion which made by a cystic renal carcinoma. She has had previous urinary tract infections. She has had some discomfort in the left flank and abdomen.

Past medical history includes previous C-section, hyperthyroidism, hypertension. Allergies nil. Medication includes Eltroxin.

Physical examination revealed a 42-year-old female in no acute distress. Head and neck and chest are clear. Abdominal exam revealed left flank discomfort with no rebound, guarding or organomegaly. The mass is not palpable.

To recap, ******* is a 42-year-old female with a nonfunctioning right kidney that has a cyst and also a solid component to it. This may be some scarring versus a benign lesion such as an oncocytoma or angiomyolipoma versus cystic renal carcinoma. If any of this is benign, because it is symptomatic with pain an discomfort, excision is recommended. After the CT scan, she will be reviewed for a final decision.

Edited Sample Report

Thank you for asking me to see Mr. ******* in a repeat consultation who was seen on ******* He is a pleasant 34-year-old male who was seen regarding having his left testicle removed. He has had a right testicular prosthesis inserted in the 1980's after a right orchiectomy. He, unfortunately continues to have discomfort in the left testicle and would like to have this removed. He was originally seen back in April of 1998, and I suggested to him he try to live with this discomfort, but he returns now about a year-and-a-half later stating that he is fed up and would like to have it removed and a second prosthesis inserted on the left side which would render him hypogonadic and would require testosterone replacement permanently.

Past medical history is as above. He has no allergies and is on no medications.

Physical examination revealed a 34-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 an atrophic left testis that is high at the external ring and also a right testicular implant that is somewhat small.

To recap, Mr. ******* is a 34-year-old male who wishes to have a left orchiopexy and also a change of the right testicular prosthesis. He understands that this will render him hypogonadic and would require testosterone replacement. I have asked Dr. ******* to review the patient to see if he is agreeable with the above with respect to his replacement hormones post-op and we will place him on the waiting list.

Edited Sample Report

Thank you for referring this patient and thank you for the accompanying information. The patient was seen in consultation on ******* She is a pleasant 29-year-old female who was seen regarding urinary urgency and urgency incontinence. This has been ongoing for the last few months. She has incontinence two to three times per day. She denies any stress incontinence, however. She has no nocturia. Her flow is normal. She has frequency four to five times in the daytime. She has no hematuria or dysuria or flank or abdominal pain. She has had normal abdominal ultrasounds. She drinks three glasses of water and also two diet Pepsi's per day.

Past medical history is unremarkable. Allergies nil. Medications nil. She doesn't smoke or drink alcohol. Family history is negative.

Physical examination revealed a 29-year-old female in no acute distress. Head and neck and chest are clear. Abdominal exam revealed no masses, no tenderness and no organomegaly. .

To recap, ******* is a 29-year-old female with significant urgency and urgency incontinence. Differential diagnosis includes detrusor instability and interstitial cystitis or bladder polyps or stones. I will arrange for a cystoscopy for a definitive diagnosis and then she will be seen for further management.

Edited Sample Report

Thank you for asking me to see ******* in a repeat consultation who was seen on ******* He is a pleasant 58-year-old male with previous back injury and surgery who is now doing intermittent catheterizations. He does them two to four times a day, obtains 300 to 500 cc each time. He is having incontinence in between catheterizations almost on a daily basis. The Ditropan does not seem to be effective. He is also having difficulty catheterizing himself with some bleeding and resistence. He has erectile dysfunction in addition. He is booked to have a rigiscan in the next one week.

Medications include Zoloft, lithium and Ditropan.

Physical examination revealed a 58-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 moderate prostate. It is, however, somewhat tender and boggy.

To recap, ******* is a 58-year-old male with some irritation, urgency and continence, difficulty in catheterizing himself. The differential diagnosis would include urethral stricture, prostatitis or a bladder lesion.

He will be placed on Cipro for the next one week because of the bogginess of the prostate and we will also arrange for a flexible cystoscopy. He will be reviewed following the rigiscan.