Urinary Retention Emergency Room Sample Report
TIME SEEN: 1800.
CHIEF COMPLAINT: “I cannot void.”
HISTORY OF PRESENT ILLNESS: The patient is a generally healthy Hispanic gentleman, who is (XX) years of age, who presents to the emergency department stating that he cannot void. The patient had pheochromocytoma removed recently here. He had some trouble voiding afterwards; however, that did resolve prior to his discharge home. He reports over the last 12 hours he has been unable to urinate. He therefore came to the emergency department for evaluation. Upon arrival, the patient was just saying that he is unable to void. He is denying any pain, nausea, vomiting, dysuria, diarrhea or constipation. The patient is without other complaints at this time.
PAST MEDICAL AND SURGICAL HISTORY: Pheochromocytoma removal, GERD, and hypercholesterolemia.
ALLERGIES: NKDA.
MEDICATIONS: Listed in chart.
REVIEW OF SYSTEMS: No fevers, chills, nausea, vomiting. Does have urinary retention. Further review of systems negative.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No tobacco, alcohol, IV drugs.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/88, pulse 92, respirations 16, temperature 98.6, and O2 sats 93% on room air and then 95% on room air.
GENERAL: The patient is in no acute distress, alert and oriented.
HEENT: Normocephalic and atraumatic. Nonicteric sclerae. Extraocular movements are intact.
NECK: Supple.
LUNGS: Respirations are unlabored.
ABDOMEN: Soft, nontender, and slightly distended throughout the suprapubic region.
GU: He does have tenderness to percussion over the area of his bladder. Normal external male genitalia. He is circumcised.
EXTREMITIES: Moves all extremities equally.
SKIN: Warm, dry, and intact.
NEUROLOGIC: Cranial nerves II through XII are intact.
PSYCHIATRIC: Alert and oriented x4. Affect appropriate.
LABORATORY DATA: The patient had urinalysis, which demonstrated no acute abnormality.
CONSULTATIONS: Urology and General Surgery.
EMERGENCY DEPARTMENT COURSE: The patient presented to the emergency department with chief complaint and history of present illness as above. He was evaluated. He was felt to have urinary retention. He has had issues with this in the past. He was not seen by Urology in house. Foley was placed, which demonstrated approximately 1000 mL of urine, removed. A leg bag was placed. We discussed the patient’s care with Urology; they suggested a double dose of 0.5 mg Flomax for day 1, then 0.4 mg q. day thereafter. Follow up with Urology next week. The patient was given the contact number to call for a followup appointment. We spoke with the on-call surgical resident to inform them of the patient having returned for this retention. The patient was stable and was discharged home.
PLAN:
1. The patient is to keep his leg bag in.
2. The patient is to take Flomax as above. He had no evidence of urinary tract infection, thus no antibiotics were given.
DIAGNOSIS: Urinary retention.
DISCHARGE CONDITION: Good.
DISPOSITION: The patient was discharged to home.
Urinary Retention Consultation Sample Report
REASON FOR CONSULTATION: Chronic urinary retention.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was admitted here because of weakness. Urology consultation was requested because of chronic urinary retention. The patient is well known to this facility because of chronic urinary retention and carcinoma of the bladder. The patient complains of bladder pain. He denies fevers. There is no report of gross hematuria. As noted earlier, the patient has been in chronic urinary retention for the past year. He has been managing the bladder with a Foley catheter to gravity drainage. Recent revisualization of the lower urinary tract found the patient to have a bladder tumor for which he underwent transurethral resection of the bladder tumor. In an effort to render the patient catheter free, he underwent a TUNA. The patient was scheduled for a voiding trial Thursday of this week. The patient has bacteriuria for which he is receiving penicillin and Levaquin.
PAST MEDICAL HISTORY: Significant for spinal stenosis, TIAs and strokes, peripheral neuropathy, hypertension, and gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Noncontributory and as previously mentioned.
ALLERGIES: CODEINE AND REGLAN.
MEDICATIONS: Includes methylphenidate, Lasix, Aggrenox, Synthroid, diltiazem, omeprazole, Detrol, multivitamins, potassium chloride, Tylenol, Metamucil, gabapentin, and citalopram.
REVIEW OF SYSTEMS: Unremarkable. The patient denies constipation.
FAMILY HISTORY: Noncontributory. There is no family history of genitourinary malignancy.
SOCIAL HISTORY: The patient is divorced.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is an obese male. He is resting comfortably in bed at the time of examination.
VITAL SIGNS: The patient is afebrile. Vital signs are stable. There is no tachycardia. Blood pressure is 106/56.
ABDOMEN: Protuberant. There is a large abdominal fat pad.
BACK: Without CVA tenderness and/or palpable flank mass.
GENITALIA: Examination of the external genitalia reveals hypospadias.
RECTAL: On digital rectal exam, the prostate gland measured 2 x 2 cm with an estimated weight of 22 grams; the gland is smooth. Perineal sensation is present. Bulbocavernosus reflex is absent.
LABORATORY DATA: White blood cell count 14.4, hemoglobin 10.2, hematocrit 30.6. BUN and creatinine are 12.2 and 1.1 mg/dL respectively. Urinalysis returned at 40-50 red cells and 8-14 white cells/hpf. Urine culture returned with Pseudomonas aeruginosa and enterococcus.
ASSESSMENT:
1. Bacteriuria, most consistent with colonization, although infection cannot be excluded.
2. Chronic urinary retention, status post transurethral needle ablation.
3. History of carcinoma of the bladder, grade 2 stage pTa transitional cell carcinoma of bladder, status post transurethral resection of bladder tumor.
4. In addition, the patient has a number of significant comorbidities.
PLAN: The plan for this patient is diagnostic and interventional, urine culture is requested. A voiding trial will be arranged during this hospitalization.
DISPOSITION: The disposition for this patient depends on his clinical course.
