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.
Edited Sample Report
The patient was seen in consultation on ******* He is a pleasant 2½-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 2½-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 2½-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 1½ 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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