Presenting complaint
The patient, Mr. John Smith, presents today for a scheduled catheter removal. He reports mild discomfort in the suprapubic region since the catheter insertion three weeks ago following a transurethral resection of the prostate (TURP). He denies any fever, chills, or dysuria. His urine has remained clear with no visible blood. His current status is stable, and he is eager for the catheter to be removed.
History:
Detailed description for first symptom: Mr. Smith describes the discomfort as a constant, dull ache, primarily in the lower abdomen, radiating slightly to the perineum.
Symptom quality and severity: The discomfort is rated 3/10 on a pain scale, intermittent but noticeable.
Symptom duration: This discomfort has been present since the catheter insertion approximately three weeks prior.
Recent illnesses or events: No recent illnesses reported apart from the TURP procedure.
Associated symptoms: No associated symptoms like urgency, frequency, burning, or haematuria.
Current treatments and their effects: He has been taking paracetamol 500mg as needed, which provides some relief from the discomfort.
Treatment planned for issue: Catheter removal is planned for today.
Past history:
Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments: Mr. Smith has a history of benign prostatic hyperplasia (BPH) leading to the recent TURP. He is otherwise healthy with no other significant medical conditions. Current medications include tamsulosin 0.4mg daily (prior to TURP, currently on hold), and paracetamol as needed. No known allergies.
Possible medication side effects if explicitly mentioned: No side effects from paracetamol reported.
Family history:
Relevant past family history and social history: Father had BPH. Mother had hypertension. No significant family history of urological cancers. Mr. Smith is retired, lives with his wife, and denies smoking or regular alcohol consumption.
Examination:
Vital signs listed, e.g. T, Sats %, HR, BP, RR: T 36.8°C, Sats 98% on air, HR 72 bpm, BP 130/80 mmHg, RR 16 breaths/min.
Findings from the physical examination, including any abnormalities: Abdomen soft, non-tender, non-distended. No suprapubic tenderness on palpation. Catheter site clean and dry with no signs of infection or irritation. Mild tenderness noted on deep palpation of the prostate region (via DRE) due to recent surgery, but no acute findings. Urine in drainage bag clear, light yellow.
Negative findings mentioned on examination: No fever, no chills, no suprapubic swelling, no penile discharge.
Physical or mental state examination findings, including system specific examination:
* General: Alert, oriented, appears comfortable.
* Abdominal: Soft, non-tender, no guarding, bowel sounds present.
* Genitourinary: External genitalia appear normal. Catheter well-secured, no leakage.
Plan:
Patient advised regarding the catheter removal procedure, which was performed successfully without complications. Post-removal, Mr. Smith was encouraged to drink plenty of fluids and to monitor his urinary output. He was informed that he might experience some temporary discomfort or burning with urination, and possibly some frequency for a day or two. He was provided with advice on managing potential post-catheterisation symptoms, including using paracetamol for mild pain. He was instructed to contact the clinic if he develops a fever, chills, significant burning or pain with urination, inability to pass urine, or heavy bleeding. A follow-up appointment was scheduled for 1 November 2024 to review his urinary function and recovery. He was given a patient information leaflet on post-catheter care.
Presenting complaint
[Describe the patient's current symptoms, surgical history, and current status relating to the catheter removal] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
History:
[Detailed description for first symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Treatment planned for issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Detailed description for next symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Treatment planned for issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Detailed description for next symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Treatment planned for issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Detailed description for next symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Treatment planned for issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Detailed description for next symptom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Treatment planned for issue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
Past history:
[Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.)
[Possible medication side effects if explicitly mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
Family history:
[Relevant past family history and social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.)
Examination:
[Vital signs listed, e.g. T, Sats %, HR, BP, RR] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Findings from the physical examination, including any abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Negative findings mentioned on examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.)
[Physical or mental state examination findings, including system specific examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely. Use as many bullet points as needed to capture the examination findings. Do not duplicate examination findings.)
Plan:
[Outline the plan including instructions for the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[Provide advice on any medication] (Only include if explicitly mentioned in transcript, context or clinical note, else omit completely. Write in paragraphs of full sentences.)
[Detail the recommended actions for patient, carer and other clinicians] (Only include if explicitly mentioned in transcript, context or clinical note, else omit completely. Write in paragraphs of full sentences.)
[Document any instructions for contacting the clinic for follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit completely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
