Edited Sample Report
Thank you for asking me to see Mr. ******* in a repeat consultation who was seen on ******* He is a pleasant 33-year-old
male who was seen regarding azoospermia. He was originally seen six months ago for the same problem, but the failed to return
for a follow-up visit. He semen analysis shows zero sperm. His investigations last visit showed his FSH was very elevated
at 54. His LH was also elevated at 15. His free serum testosterone was quite low at 8, normal being between 30 and 87. Ultrasound
shows no real functioning testicular tissue and that is the cause of his azoospermia, high FSH and LH and also very low testosterone.
He is also now beginning to express problems with erections with poor rigidity and decreased libido.
Past medical history as above.
Physical examination revealed a 33-year-old male in no acute distress. Head and neck and chest are clear. Abdominal exam
revealed no masses, no tenderness and no organomegaly. Examination of genitalia again shows very tiny atrophic left testes.
The right one is not palpable.
To recap, ******* is a 33-year-old male with azoospermia, infertility, primary testicular failure. This is not affecting
his erections. In this gentleman, there is a strong indication of testosterone replacement and, therefore, he will be placed
on Delatestryl 1.0 cc every three weeks IM for the next three months at which time I will do a repeat serum testosterone levels.
I am afraid that this gentleman will never be fertile, but hopefully, we can get his hormonal status in the normal range so
he can function as a normal male. He will be reviewed in three months' time.
Edited Sample Report
Thank you for referring this patient and thank you for the accompanying information. The patient was seen in consultation
on ******* He is a pleasant 63-year-old male who was seen regarding testicular pain. This has been ongoing intermittently
for the last few years. He also has significant obstructive symptoms with a slow flow and nocturia x 10, and frequency q.
1 h.
Past medical history includes coronary disease, bypass surgery, angioplasty, previous TUPR, hepatitis C positive. Allergies
nil. Medications include Cardizem, Nitrong, Cozaar, Zocor and Serax. Family history is negative.
Physical examination revealed a 63-year-old male in no acute distress. Head and neck and chest are clear. Abdominal exam
revealed no masses, no tenderness and no organomegaly. Genitalia were normal. DRE shows an enlarged prostate.
To recap, ******* is a 63-year-old male who has had previous prostatic intervention with significant obstructive symptoms
once again. Differential diagnosis includes urethral stricture, bladder neck contracture versus BPH. I would like to arrange
for a flexible cystoscopy for definitive diagnosis and then he will be seen for further diagnosis.
Edited Sample Report
Thank you for asking me to see Mr. ******* in a repeat consultation who was seen on ******* He is a pleasant 74-year-old male
who was seen regarding prostatic carcinoma. He was originally seen for urinary retention back in November, at which time he
had a TUPR. Pathology has returned this as 5/10 prostatic carcinoma and less than 5% of the tissue make it a stage A1. He
is currently voiding well with a good flow and nocturia x 1 and no problems with obstruction.
Past medical history reveals previous kidney stones. He is allergic to PENICILLIN.
Physical examination revealed a 74-year-old male in no acute distress. Head and neck and chest are clear. Abdominal exam
revealed no masses, no tenderness and no organomegaly. Genitalia is normal. DRE showed a small contracted prostate.
To recap, ******* is a 74-year-old male with stage A1 prostatic carcinoma. PSA is stable at 1.3 and because he is at advanced
age, this should be followed up conservatively. I would suggest a PSA in six months' time, at which he should be reviewed.
He is also having some problems with his erections and on close questioning, he did not state he had any significant cardiac
history and he is not on any nitrates and, therefore, he was given a trial of Viagra at 50 mg.
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