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泌尿科標準病歷範本
Case 1: Benign prostatic hyperplasia
(BPH)
Chief complaint:
LUTS for years
Present illness:
According to his previous chart, he denied any precursor system disease. He had
LUTS for over 5 years ago and acute urine retention years ago, and had medication
when visiting LMD for the first time. Nevertheless, the signs and symptoms were
exacerbated including the nocturia was 2-3 times pernight. Then the prostate survey
was done. Digital rectal exmination showed prostate enlargement with smooth
rubbery surface. PSA was 0.39 ng/dl (<4 ng/dl). The uroflometry revealed the low
mean and maximum urinary flow rates. Moreover, the transrectal ultrasound (TRUS)
evidenced the enlarged prostate volume about 41cc. So he was admitted for
transurethral resection of prostate (TURP).
Impression :
1 Prostate enlargement
2 HCVD
3 CAD
Plans:
1. Diagnostic plan： arrange surgical resection for BPH
2. Therapeutic plan：

IV hydration

Pre-PRBC 2 unit

Arrange operation for green light laser and TUR-Biopsy
3. Educational plan：
1.請您務必於出院後繼續按時服用藥物及適度水分攝取，依照前列腺肥大術後注
意事項休
養並於週四上午至泌尿科門診追蹤。
2.您如有發燒、解尿困難或嚴重血尿情形，請您馬上至本院急診追蹤治療。
3.您有高血壓病史，請按時監測血壓，並至心臟內科門診追蹤治療。
4. 您的胸部 x 光檢顯示右肺葉結節，請胸腔內科門診追蹤。
5.
Case 2: Renal tumor (RCC)
Chief complaint:
Intermittent hematuria for 9 months and symptom progressed recently.
Present illness:
This 66-year-old female of DM and hypertension under regular medical control for
decades had transient painless gross hematuria since this March and at first paid no
attention to it until the hematuria (The fresh blood dripped before the urination)
progressed this April. Thus, she visited Tainan Municipal Hospital, where cystitis was
told and some medications were supplied. Still, no symptom improved; suprapubic
discomfort appeared in recent half month. Thus, she came to our GU OPD on
10-07-2010 where malignancy was suspected. Echo on 10-20-2010 exhibited the right
renal cyst and mild hydronephrosis. Repeated urine cytology on 99-11-21 manifested
malignant cells which were likely urothelial carcinoma. Elevated creatinine (1.53
mg/dl) was also attested then. IVP averred right hydronephrosis and hydroureter till
the M/3 ureter (either due to the tumor growth or radiolucent stone). Bilateral URS +
cystoscopy with biopsy was to differentiate diagnosis. The pathology pictured
urothelial carcinoma of the right M/3 ureter; the CT, right mild ureteral TCC with
obstructive uropathy cT3N0M0. She denied fever, fatigue, body weight loss or poor
appetite recently. Otherwise, dyspnea on exertion was told, and was likely related to
obesity. For upper urothelial carcinoma, she was admitted for surgery and further
management.
Impression
1 Urothelial carcinoma of right ureter,stage I, T1N0M0
2 Gastric ulcer
3 Chronic renal insufficiency
Plans:
6. Diagnostic plan： Arrange surgical resection of tumor
7. Therapeutic plan：
1.Pre-op preparation.
2.Arrange Nephroureterectomy on 99-11-18.
3.Discuss with Nephrologist to see if arrange A-V shunt before surgery.
8. Educational plan：
a.請您於下週至泌尿科門診追蹤檢查及傷口安排拆線。
b.請保持傷口清潔乾燥並請繼續使用束腹帶束腹至少三個月，若傷口有異常紅
腫、疼痛、
發燒（＞38.5C）或不正常分泌物，請盡速至急診追蹤。
C 您有糖尿病病史請規則服藥及自我血糖監測。
D 胃潰瘍請肝膽腸胃追蹤及服藥，採清淡飲食及注意有無解黑色柏油糞便復發
情形
E 手術後顯示慢性腎功能不全，門診續追蹤腎功能抽血檢查及採低鹽飲食
F 手術後病理報告顯示輸尿管移行性上皮癌，故需門診持續追蹤膀胱鏡檢查，預
防及早期發現膀胱腫瘤
Case 3: Fournier gangrene
Chief complaint:
Fever, chills and perineal pain for 3 days
Present illness:
The 69-year-old man had previous history of DM. Now, he suffered from fever, chills
and perineal pain for 3 days. He denied upper respiratory infection and GI symptoms.
But urinary retention was showed since yesterday. Then he went to our emergency
room. Physical examination showed the perianal redness with local tenderness,
involving the scrotum. Under the impression of Fournier gangrene, he was admitted
for further operation.
Impression :
Fouriner gangrene
Plans:
9. Diagnostic plan：Adequate debridement
10. Therapeutic plan：


Arrange colostomy and debridement
pre op survey

Abx for infection control
11. Educational plan：
1.請保持傷口乾燥清潔，並至泌尿科門診回診，以檢視傷口情形。
2.返家後如有發燒、傷口紅腫或異常分泌物請立即回診。
3.重症肌無力病史請持續服藥及神經內科門診追蹤
Case 4: Inguinal hernia
Chief complaint:
Right inguinal protruding soft mass for 3 month
Present illness:
According to the patient and previous chart, he had previous left inguinal hernia s/p
herniorrhaphy. This time he suffered from the protruding soft mass in the right
inguinal region for 3 months before coming to our GU OPD which certified
spontaneous reduction in relaxation. Despite no fever, there was mild tenderness. For
right inguinal hernia, he was admitted for operation.
Impression :
Right inguinal hernia, indirect
Plans:
12. Diagnostic plan：surgical repair of hernia
13. Therapeutic plan：Arrange operation for right herniorrhaphy
14. Educational plan：
A 請保持傷口清潔藥，於下週二至泌尿科門診回診，以檢視傷口癒合情形
B 請三個月內勿提搬重物，勿跑步，避免需增加腹壓之動作，以免疝氣復發。
C 若傷口或陰囊有異常紅腫、分泌物或嚴重疼痛的情況，請速就醫求診。
Case 5: Renal cyst
Chief complaint:
Right flank dullness pain for weeks
Present illness:
According to the patient and previous chart, he had previous HCVD and CAD S/P
CABG in our CV OPD follow up with regular medications. Furthermore, the bilateral
renal cysts were identified, beside LUTS in our GU OPD follow up. The abdominal
echo evidenced the right renal cyst enlarged from 5.8 cm to 7 cm. No flank pain or no
fever was noted. For the cysts, he was admitted for surgery.
Impression :
1 Right renal cyst
2 Coronary artery disease
3 Hypertensive cardiovascular disease
Plans:
15. Diagnostic plan：
Laparoscopic unroofing renal cyst, retroperitoneal method
16. Therapeutic plan：
Arrange operation for laparscopy unroofing renal cyst
17. Educational plan：
i.請您務必請至泌尿科門診追蹤。
ii.請您傷口每日用優碘消毒並保持乾燥及記錄每日引流管量，預門診拔除。
iii.出院後請適量水分補充、均衡飲食及適度運動。
Case 6: Bladder cancer
Chief complaint:
Suspected urinary bladder recurrent after first operation
Present illness:
According to the patient, he had lasting hypertension, beside Type II DM Type II DM
history treated with regular medications at the health center, and GB and CBD stones
at the GI OPD follow up.
He had intermittent painless gross hematuria for one year, asides from urinary bladder
tumor s/p TUR-BT with final diagnosis of urothelial carcinoma 3 months ago, and the
regular GU OPD follow up by IVC-plied mitomycin. At follow up, the cystoscopic
examination expressed urethral stricture without urinary bladder tumor recurrence.
Nevertheless, the abdominal echo showed: recurrent urinary bladder tumor; right
hydronephrosis. So, he was admitted for second-look surgery for urinary bladder
tumor and further treatment.
Impression
1. Urinary bladder Transitional cell carcinoma, T1N0M0, stage I, s/p Transurethral
resection of bladder tumor without recurrence
2. Hypertensive cardiovascular disease
Plans:
18. Diagnostic plan：Arrange operation for 2 nd TUR-BT
19. Therapeutic plan：Arrange operation for 2 nd TUR-BT
20. Educational plan：
a.請於下週四上午至泌尿科門診追蹤及等待病理報告。
b.請您務必於出院後繼續按時服用藥物，攝取適量水份。
c.若有發現嚴重血尿、劇烈腰痛或發燒（38.5C）的情況，請您盡速就 醫求診。
d 高血壓病史，住院期間血壓偏高，返家請持續自我血壓監測，必要時相關內科
門診藥物調整服用
治療效果：沒有改善但也沒有惡化
Case 7: Prostate cancer
Chief complaint:
Prostate cancer history, hesitancy, small caliber of u-stream, terminal dribbling,
nocturia three times pernight for 6 month.
Present illness:
This 80 y/o male had previous prostate cancer (T2bN0M0), in addition to TUR-P for
2 times. For hesitancy, small caliber stream, terminal dribbling, and nocturia 3/night
for 6 months, he was brought to our GU OPD before the TRUS proved the prostate
enlarged about 4.46 x 5.49 x 4 cm in size and 51.3 c.c. in volume. Additionally, PSA
was 62.34 ng/mL; IPSS, 20. The uroflowmetry mean flow was 3.4 ml/sec; the max.
flow, 9.6 ml/sec. The digital examination evinced the smooth surface of the hen egg
size prostate without tenderness. For probable prostate cancer growth, he was
admitted for the pre-op evaluation and recommended TUR-P.
Impression
Prostate adenocarcinoma T2bN0M0, stage II, Gleason score:3+4, high risk
Plans:
Diagnostic plan：Palliative TUR-P
Therapeutic plan：Palliative TUR-P
Educational plan：
治療效果：主要症狀明顯進步
A.
請您務必於出院後繼續按時服用藥物及適度水分攝取，並依照前列腺
肥大術後注意事項休養，請於至泌尿科門診追蹤病理報告結果。
B.
建議每年到泌尿科門診追蹤 PSA。
C.
您返家後如有解尿困難、發燒（38.5 C）或嚴重血尿情形，請您馬上
至本院急診或門診處理治療。
D.
請三個月內勿騎腳踏車及機車或搬重物。
Case 8: Renal stone
Chief complaint:
Sudden onset of gross hematuria since 2 days ago
Present illness
This 54 y/o male had no systemic history. For the sudden onset of painless gross
hematuria with blood clots since 2 days ago, and the dysurea, he without flank pain,
fever, and chillness was brought to our ER. The lab data divulged leucocytosis with
elevated CRP and UA bacteriuria; the KUB, no obvious urinary stone; the abdominal
echo, the left renal stone. He was treated by Cefazolin + GM at ER where high fever
up to 39.0 degree was declared. The hematuria was gradually improved, but fever and
chillness persisted. For the left renal stone and urinary tract infection, he was admitted
for further treatment after complaining of soreness sensation while voiding with a
weak urine stream for about one year. The bladder scan volume was 2 ml. PSA was to
be checked for the prostate lesion.
Impression:
Left renal stone
Urinary tract infection
Prostate enlargement
Plans:
Diagnostic plan：Arrange PCNL
Therapeutic plan: Arrange PCNL
Educational plan：
A.請按時服藥，於下週一上午至泌尿科門診及胸腔科門診追蹤。
B.請持續按規定服用抗生素藥物，並至門診做追蹤。
C.返家後若有持續高燒、嚴重血尿等問題請至急診或門診追蹤。
D.您右肺部 X 光片有一結節,建議至胸腔科門診追蹤
Case 9: Bladder stone
Chief complaint :
Turbid and foul smelling urine was noted in recent 1 month
Present illness:
The 50-year-old male denied previous systemic disease. His total hearing loss was
due to traffic accident about 20 years ago. He had preceding bladder stone, beside
cystolithotomy on 4-2-2002, and vesicolithotripsy on 2-18-2005 and 2-6-2009. The
foley indwelling catheter was attributed to urine retention for many years. He went to
our OPD for foley catheter changing and bladder irrigating monthly. Recently, he
found the turbid and foul-smelling urine. The clinical impression was bladder stone
which was indicated on KUB on 11-21-2010. Hence, he was admitted to our ward on
11-21-2010 for surgical management.
Impression :
Multiple urinary bladder stone
Plans:
Diagnostic plan：Arrange vesicolithostripsy
Therapeutic plan: Arrange vesicolithostripsy
Educational plan：
a.請您於出院後繼續按時服用藥物
b.請保持傷口清潔及每日按時換藥。
c.請於下週一至泌尿科門診追蹤。
d.請於門診看病理報告
Case 10: Testis tumor
Chief complaint :
Left scrotum swelling for 3 months.
Present illness:
This 73 y/o male had previous bladder TCC s/p TURBT, beside the intravesical
chemotheraphy (IVC) with BCG immunocyst therapy. After IVC, the urinary tract
tuberculosis infection occurred, and so did the left scrotum swelling for 3 months.
Hence, he visited our GU OPD. The malignant left testicular mass was likely, so he
was admitted for pre-op evaluation and left radical inguinal orchiectomy.
Impression:
Left testis tumor suspected seminoma
Plans:
Surgical resection of testis tumor
Diagnostic plan : Left radical inguinal orchidectomy
Therapeutic plan: Left radical inguinal orchidectomy
Educational plan：
a.請您於出院後繼續按時服用藥物
b.請保持傷口清潔及每日按時換藥。
c.請於下週一至泌尿科門診追蹤。
d.請於門診看病理報告