泌尿科英文病歷模板

1、Sample History and Physical NoteCharting Plus - Electronic Medical RecordsNote for Cameron Carre on 4/2/03 - Chart 21875Date of Last Physical Exam: 09/18/2002, New patientDate of Birth: 05/16/1941 Age: 61Marital status of patient is: married. The number of children the patient has is 4.Chief Complai

2、nt (1/1: This 61 year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml.Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to emptybladder, nocturia, urinary hesitancy and urine stream is slow.Timing (onset/frequency: Onset was

3、 6 months ago.Patient denies fever and chills and denies flank pain.Allergies: Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia. Medication History: Patient is not currently taking any medications.Past Medical History: Childhood Illnesses: (

4、+ asthma, Cardiovascular Hx: (- angina, Renal / Urinary Hx: (- kidney problems.Past Surgical History: Patient admits past surgical history of appendectomy in 1992.Social History: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history,

5、Patient denies tobacco use.Family History: Patient admits a family history of gout attacks associated with father.Review of Systems: Unremarkable with exception of chief complaint.Physical Exam: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6Patient is a pleasant, 61 year-old male in no apparent distr

6、ess who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.Neck: Neck is normal and symmetrical, without swelling or tenderness.Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.Respiratory: Respirations are even without

7、 use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal.Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks.Peripheral pulses full to palpatio

8、n, no varicosities, extremities warm with no edema or tenderness.Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity.Hernia: absent; no inguinal, femoral, or ventral hernias noted.Liver and/or Spleen: no abnormalities, tenderness, or masses

9、noted.Stool specimen not indicated.Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted.Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted.Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or te

10、nderness.Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.Penis: no abnormalities; circumcised; no phimosis, peyronie's, condylomata, or lumps noted.Prostate: size 60 gr, RT>LT

11、and firm.Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesi

12、ons or ulcers observed.Neurological/Psychiatric: Oriented to person, place and time.Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.Test Results: No tests to report at this time.Impression: Elevated prostate specific antigen (PSA.Plan:Cystoscopy in the off

13、ice.Diagnostic & Lab Orders: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA. Ordered ultrasound of prostate.I have discussed the findings of this follow-up evaluation with the patient. The discussion included a c

14、omplete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions. Instructed Ben to avoid caffeina

15、ted or alcoholic beverages and excessively spiced foods. Questionsanswered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850.Prescriptions :Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: N

16、oPatient Instructions:Patient completed benign prostatic hyperptrophy questionnaire_ Dr. Urologist, M.D.Sample Referral LetterCharting Plus - Electronic Medical Records4/2/03A. General Practitioner1231 8th StreetWest Des Moines, IA 50265Dear Dr. General Practitioner:Cameron Carre was seen in my offi

17、ce for evaluation following your initial referral. Thank you again for allowing me to participate in the care of your patients. In an attempt to provide your patients with quality patient care through improved communication, the following represents my notes from their last office visit:Date of Last

18、 Physical Exam: 09/18/2002, New patientDate of Birth: 05/16/1941 Age: 61Marital status of patient is: married. The number of children the patient has is 4.Chief Complaint (1/1: This 61 year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml.Associated signs and symptoms: A

19、ssociated signs and symptoms include dribbling urine, inability to emptybladder, nocturia, urinary hesitancy and urine stream is slow.Timing (onset/frequency: Onset was 6 months ago.Patient denies fever and chills and denies flank pain.Allergies: Patient admits allergies to adhesive tape resulting i

20、n severe rash. Patient denies an allergy to anesthesia. Medication History: Patient is not currently taking any medications.Past Medical History: Childhood Illnesses: (+ asthma, Cardiovascular Hx: (- angina, Renal / Urinary Hx: (- kidney problems.Past Surgical History: Patient admits past surgical h

21、istory of appendectomy in 1992.Social History: Patient admits alcohol use Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.Family History: Patient admits a family history of gout attacks associated with father.Review of Systems:

22、Unremarkable with exception of chief complaint.Physical Exam: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6Patient is a pleasant, 61 year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.Neck: Neck is normal and

23、 symmetrical, without swelling or tenderness.Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal.Lungs clear to

24、auscultation with no rales, rhonchi, wheezes, or rubs noted.Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks.Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalitie

25、s, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted.Liver and/or Spleen: no abnormalities, tenderness, or masses noted.Stool specimen not indicated.Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness no

26、ted.Scrotum: no abnormalities. No lesio ns, rash, or sebaceous cyst noted.Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.Urethral Meatus: no abnormalities; no hyposp

27、adias, lesions, polyps, or discharge noted.Penis: no abnormalities; circumcised; no phimosis, peyronie's, condylomata, or lumps noted.Prostate: size 60 gr, RT>LT and firm.Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.Sphincter tone: no abnormalit

28、ies; good tone; without hemorrhoids or masses.Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed.Neurological/Psychiatric: Oriented to person, place and time.Mood and affect normal, appropriate to situatio

29、n, without depression, anxiety, or agitation.Test Results: Not returnedImpression: Elevated prostate specific antigen (PSA.Plan:Cystoscopy in the office.Diagnostic & Lab Orders: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific

30、antigen (PSA. Ordered ultrasound of prostate.I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgica

31、l procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions. Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questionsanswered. If any questions should arise after returning home I have encouraged the pa

32、tient to feel free to call the office at 327-8850.Prescriptions:Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: NoPatient Instructions:Patient completed benign prostatic hyperptrophy questionnaireIf I may be of any further assistance in the care of this patient, pl

33、ease let me know.Sincerely,Dr. Urologist, M.D.Sample Patient InstructionCharting Plus - Electronic Medical RecordsPatient Instructions for Cameron Carre on 4/2/2003BENIGN PROSTATIC HYPERPLASIACircle the numerical score for each question below.OVER THE LAST MONTH OR SO:1. How many times did you most

34、typically get up to urinate from the time you went to bed at night until the time you got up in the morning?None 01 time 12 times 23 times 34 times 45 or more times 52. How often have you had a sensation of not emptying your bladder completely after you finished urinating?Not at all 0Less than 1 time in 5 1Less than half the t