Urology Specialist's Documentation Template

Diagnoses and Plan:
- Benign Prostatic Hyperplasia (BPH) with urinary retention. Plan includes medication management and lifestyle changes.
Reason for the Consultation:
- The patient presented with frequent urination, urgency, and nighttime urination.
History of presenting complaint:
- The patient reports a 6-month history of increased urinary frequency and urgency, with nighttime urination occurring 3-4 times per night. Symptoms have gradually worsened, and the patient experiences difficulty starting urination. No previous treatments have been attempted.
Past Medical History:
- History of hypertension, managed with medication. No previous urological surgeries or interventions.
Pharmacological History:
- Currently taking Lisinopril 10mg daily for hypertension. No medications for urological conditions.
Social History:
- The patient consumes 2-3 cups of coffee daily and drinks alcohol socially. No history of smoking. Works as an accountant.
Allergies:
- No known drug allergies.
Objective:
- Vitals: BP 130/85 mmHg, HR 78 bpm, oxygen saturation 98% on room air, temperature 36.8°C.
- General examination: No pallor, icterus, or lymphadenopathy. No pedal edema.
- Physical examination: Abdominal examination revealed a distended bladder. Digital rectal examination indicated an enlarged prostate, smooth and non-tender. A chaperone was present during the examination.
- Investigations: Urinalysis showed no signs of infection. Ultrasound of the bladder and prostate confirmed an enlarged prostate with post-void residual volume of 150ml.
Assessment & Plan:
1. Benign Prostatic Hyperplasia (BPH)
- Assessment: Likely diagnosis of BPH based on symptoms and examination findings.
- Differential diagnosis: Urethral stricture, bladder stones.
- Investigations planned: Uroflowmetry to assess urine flow rate.
- Medical treatment planned: Start Tamsulosin 0.4mg daily to improve urinary flow.
- Lifestyle modifications: Advise reduction in caffeine and alcohol intake, encourage regular pelvic floor exercises.
- Follow-up appointments: Review in 6 weeks to assess response to treatment and adjust management if necessary.
Additional Notes:
- Patient education provided on BPH, including potential complications and the importance of medication adherence.
- Instructions given to monitor symptoms and seek urgent care if experiencing severe pain or inability to urinate.