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Urology Medical Transcription Consultation Sample

DATE OF CONSULTATION: XX/XX/XXXX

CONSULTING PHYSICIAN: John Doe, MD

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION: Hematuria.

BRIEF HISTORY: This is a (XX)-year-old male admitted now with chest pains. He has a history of hypertension and recurring chest pains. When I spoke with him, he says for at least 6 months, he has been bothered by a right-sided flank pain as well as microscopic hematuria. He denies any history of kidney stones, denies nocturia, denies urinary incontinence, denies nausea or vomiting, denies fevers.

PAST MEDICAL HISTORY: Hypertension and possible cardiac problems.

PAST SURGICAL HISTORY: Denied.

MEDICATIONS: He takes no medication on a daily basis.

ALLERGIES: UNKNOWN.

SOCIAL HISTORY: He is divorced. He does not smoke or drink.

FAMILY HISTORY: He says he has a son with kidney problems.

REVIEW OF SYSTEMS: Constitutional: No fevers. No weight loss. Cardiac: He was admitted with chest pains. Presently, he says he is not having any chest pains. Pulmonary: No cough or hemoptysis. Gastrointestinal: No nocturia. Positive for intermittent gross hematuria, right flank pain.

PHYSICAL EXAMINATION: General: Pleasant, middle-aged gentleman who is lying quietly in bed. Vital Signs: Temperature is 97.2, pulse is 58 and regular and blood pressure is 112/72. HEENT: Atraumatic and normocephalic. Extraocular muscles are intact. Sclerae are anicteric. Neck: Trachea midline, 2+ carotids, no bruits. Cardiac: Regular rate and rhythm. Chest: Both lung fields clear. Abdomen: Soft and nontender. There are no masses noted. Normoactive bowel sounds. Genitourinary: The bladder is not palpably distended. He complains of mild tenderness on percussion of the right flank. The phallus is a normal-appearing phallus. The foreskin retracts easily. Urethral meatus, normal caliber, normally placed. No lesions are noted. Scrotum, testes descended bilaterally, palpably normal. Digital rectal exam, no masses in the rectal vault. Prostate is about 25-30 grams. It is smooth and nontender. There is no blood on the gloved finger. Extremities: Full range of motion. No calf tenderness. No clubbing, cyanosis or edema is noted.

IMPRESSION: The patient is a (XX)-year-old gentleman with right flank pain, intermittent gross hematuria. No history of tobacco use. He needs a full hematuria workup.

PLAN:
1. CT scan of the abdomen and pelvis with and without contrast.
2. Urine cytology.