Date: [DATE]
Patient: [PATIENT NAME]
MRN: [MEDICAL RECORD NUMBER]
Attending Physician: [DOCTOR NAME]
Subjective:
Present illness: Briefly summarize the patient’s current urinary symptoms, including onset, duration, severity, and frequency. Note any associated symptoms like dysuria (painful urination), hematuria (blood in urine), urgency, frequency, fever, chills, perineal pain, or ejaculatory discomfort.
Past medical history: Briefly mention any relevant past medical history, including urinary tract infections (UTIs), sexually transmitted infections (STIs), prostate-related issues (surgery, biopsy), and allergies to medications.
Social history: Briefly mention any pertinent social factors, such as sexual activity (frequency, number of partners, use of protection), recent travel, and occupational exposures.
Objective:
Vital signs: Record current vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.
Physical exam:
General: Note appearance of illness, signs of systemic infection (fever, chills).
Genitourinary:
Inspect for genital lesions or discharge.
Perform abdominal and flank palpation to assess for kidney tenderness.
Conduct a digital rectal exam (DRE) to assess prostate size, tenderness, bogginess (softness), and fluctuance (fluid collection).
Laboratory:
Mention results of relevant laboratory tests, including:
Urinalysis (looking for white blood cells, bacteria, blood)
Urine culture and sensitivity (identifies specific bacteria and best antibiotics)
Complete blood count (CBC) with differential (elevated white blood cells may suggest infection)
Consider sexually transmitted infection (STI) testing if appropriate.
Imaging: Note any imaging studies performed (e.g., transrectal ultrasound) and significant findings (e.g., prostate abscess).
Assessment:
Summarize the patient’s clinical presentation, incorporating findings from history, physical exam, and laboratory/imaging studies.
State the working diagnosis (e.g., acute bacterial prostatitis) with a level of certainty (e.g., highly likely, possible).
Plan:
Outline the treatment plan, including:
Antibiotics – Specify the type, dose, duration of treatment based on culture results.
Alpha-blockers – Consider medications to relax the prostate muscles and ease urinary symptoms.
Pain management – Mention medications for pain relief (e.g., NSAIDs).
Supportive measures – Encourage increased fluid intake, warm sitz baths, and avoiding straining during urination.
Repeat laboratory testing – Indicate any planned follow-up tests to monitor response to treatment (e.g., repeat urine culture after completing antibiotics).
Re-evaluation – Schedule a follow-up appointment to assess symptom improvement and discuss next steps.
Note: This is a template and specific details may vary depending on the individual patient and their clinical course.