Date:
Patient: [Patient Name], [Age], [Medical Record Number]
Attending: [Physician Name]
I. Subjective
Information obtained from patient (if alert and able) or from chart review:
Mechanism of injury (fall, crush injury, sexual activity, etc.)
History of present illness:
Onset and severity of pain (location, character)
Difficulty with urination or bloody discharge from the urethra
Swelling, bruising, or deformity of the penis
Inability to achieve or maintain an erection (erectile dysfunction)
Numbness or tingling in the penis
Associated injuries (scrotum, groin, abdomen)
Past medical history (relevant conditions like bleeding disorders)
Medications (current medications)
Allergies
II. Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of shock or bleeding)
Abdominal examination (distention, tenderness)
Genital examination:
Inspection of the penis for:
Swelling, bruising, or deformity (shaft, glans)
Lacerations or puncture wounds
Subcutaneous crepitus (crackling sound) – suggestive of air under the skin
Palpation of the penis for:
Tenderness
Urethral integrity (palpable urethral disruption)
Assessment of glans penis appearance (circumcised or uncircumcised)
Scrotal examination (swelling, tenderness, hematoma)
III. Assessment
Penile trauma:
Type of injury (closed vs. penetrating)
Specific structures involved (urethra, corpus cavernosum, corpus spongiosum, glans)
Severity of injury (based on physical exam findings)
Consider differential diagnoses (balanitis, cellulitis)
IV. Plan
Imaging studies (depending on severity and suspected injury):
Ultrasound of the penis (initial imaging to assess corpus cavernosum and corpus spongiosum)
Cavernosography (optional, for complex vascular injuries)
Urethrogram (if urethral injury suspected)
Blood tests (complete blood count) to assess for blood loss
Pain management (medications)
Tetanus prophylaxis (if not up to date)
Depending on the severity and type of injury, consider:
Urology consultation for definitive treatment
Catheterization (urinary catheter) for urinary diversion (if urethral injury suspected)
Debridement and irrigation (cleaning and removing damaged tissue) for open wounds
Surgical repair (urethral reconstruction, corporal bodies)
V. Progress
Briefly summarize the patient’s progress over the past 24 hours:
Changes in vital signs and pain level
Response to interventions (pain management)
Imaging results (if available)
VI. Prognosis
Discuss the anticipated course of recovery based on injury severity:
Potential complications (infection, erectile dysfunction, urethral stricture)
Need for future interventions (surgery)
VII. Follow-up
Schedule for next appointment:
Close monitoring for signs of infection or bleeding
Follow-up imaging (if needed) to monitor healing
Referral for specialized care (urology)
VIII. Notes
Document any additional information relevant to the patient’s care, such as:
Communication with family members
Need for erectile dysfunction rehabilitation (if applicable)