DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Urinary retention.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of chest pain who was admitted for coronary artery bypass surgery. After surgery, he failed trial of void and Foley catheter was reinserted. He denies any history of urologic workup in the past; although, he believes he may have seen an urologist for a large hydrocele many years ago, but he cannot remember who it is. He reports chronic urinary tract symptoms, including frequency, urgency, nocturia and occasional sense of incomplete emptying. He denies any urologic medications in the past.
PAST MEDICAL HISTORY: Hypertension, hyperglycemia, and coronary artery disease.
PAST SURGICAL HISTORY: Coronary bypass surgery as mentioned above.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS:
1. Januvia.
2. Lasix.
3. Lipitor.
4. Glipizide.
5. Coumadin.
6. He recently was started on Flomax yesterday when the Foley catheter was reinserted.
SOCIAL HISTORY: Denies tobacco or alcohol.
FAMILY HISTORY: Positive for coronary artery disease. Negative for urologic malignancies.
PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile. His T-max was 100.2 degrees. He has a urine output of 150 mL. Blood pressure was 142/66.
GENERAL: He is alert and oriented x4. He is sitting up in a chair.
HEENT: He is normocephalic, atraumatic.
ABDOMEN: Soft, nontender, and nondistended.
GENITOURINARY: He has a large umbilical hernia that he reports has been chronic. He had a large right hydrocele he reports has been chronic for many years. Normal phallus without lesion. Normal urethral meatus. Foley catheter in good position. He refuses prostate exam.
EXTREMITIES: No clubbing, cyanosis. Mild edema.
SKIN: He has a sternotomy, well healed.
LABORATORY STUDIES: Creatinine is 2.14, BUN 70, white count 10,200, hematocrit 32.2.
IMPRESSION AND PLAN:
1. Urinary retention, likely combination multifactorial. He may have some baseline benign prostatic hypertrophy as well. Hopefully, he will allow us to examine his prostate in the future when he is more ambulatory, but for now, we would continue Flomax to rest the bladder given a trial void in 3-5 days. If he fails another trial of void, then he will follow up as an outpatient, and we will perform further evaluation in the office.
2. Renal insufficiency, chronic.
3. Right large hydrocele. He defers any surgical intervention, and it has been present for many years.
