Following is an abstract of a simulated patient’s medical record. Read the record and define each term in italics. If you can’t think of the meaning, hover your cursor over the word for a tip.
A 55 year old male complains of nocturia, three to four times a night.He also states that he has difficulty getting urination started, has a small stream, and dribbles after he finishes. Sometimes he has feelings of urgency. A review of organ systems reveals that his angina, which he treats with nitroglycerine tablets, is increasing in frequency.
A rectal exam reveals prostatic hypertrophy without nodules, most likely BPH. Patient was scheduled for an ECG and coronary angiography. A referral was made to a urologist for evaluation for a TURP.
Recent medical history: hemoptysis two months ago. Bronchoscopy was unremarkable.
Past medical history: cholelithiasis treated with cholelithotripsy at age 52. Varicocelectomy at age 28. Appendectomy at age 24.
In plain English
A 55 year old male complains of having to get up at night to urinate, three to four times a night. He also states that he has difficulty getting urination started, has a small stream, and dribbles after he finishes. Sometimes he has an urgent need to urinate. A review of organ systems reveals that his cardiac related chest pain, which he treats with nitroglycerine tablets, is increasing in frequency.
A rectal exam reveals an enlarged prostate without nodules, most likely Benign Prostatic Hypertrophy (nonlife-threatening enlargement of the prostate). Patient was scheduled for an electrocardiogram (recording of the electrical activity of the heart) and X-rays of the arteries of the heart. A referral was made to a specialist in diseases of the male reproductive system and lower urinary tract for possible transurethral resection of the prostate (partial internal removal of prostatic tissue).
Recent medical history: spitting up blood from the lungs two months ago. Passing a fiberoptic instrument into the lung passageways did not determine a cause.
Past medical history: gallstones treated with high frequency sound waves smashing stones to small particles that can pass in the stool at age 52. Removal of enlarged testicular veins at age 28. Removal of appendix at age 24.