Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) Dementia unspecified without behavioral disturbance Other B-complex deficiencies Other specified retention of urine Incomplete bladder emptying Bladder neck obstruction Asymptomatic human immunodeficiency virus [HIV] infection status Unspecified viral hepatitis C without hepatic coma Unspecified essential hypertension Arthrodesis status Depressive disorder not elsewhere classified Anxiety state unspecified
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: UROLOGY
 
Allergies: 
Darvon / Penicillins / Codeine / Motrin
 
Attending: ___.
 
Chief Complaint:
BENIGN PROSTATIC HYPERTROPHY WITH URINARY RETENTION, INCOMPLETE 
BLADDER EMPTYING, REQUIRING CLEAN INTERMITTENT CATHETERIZATION.
 
Major Surgical or Invasive Procedure:
BIPOLAR TRANSURETHRAL RESECTION OF PROSTATE

 
History of Present Illness:
Mr. ___ is a ___ year old male who presents for 
transurethral resection of prostate.
 
Past Medical History:
Depression  
? mild dementia  
HIV on HAART  
Hepatitis C, reportedly s/p interferon treatment 
self-administered for ___ year  
Hypertension  
Lumbar Stenosis s/p spinal fusion in ___ for back pain  
Sciatica  
BPH  
urinary retention  
anxiety  
B12 deficiency
 
Social History:
___
Family History:
Father was an alcoholic and died of complications, unsure of how 
mother died
 
Physical ___:
WDWN male, nad, avss
abdomen soft, nt/nd
extremities w/out edema, pitting, pain.
foley has been removed
 
Pertinent Results:
___ 09:05AM BLOOD Glucose-101* UreaN-10 Creat-1.0 Na-136 
K-3.5 Cl-100 HCO3-28 AnGap-12
___ 02:24PM BLOOD Glucose-94 UreaN-16 Creat-1.5* Na-135 
K-3.9 Cl-99 HCO3-27 AnGap-13
___ 02:24PM BLOOD Calcium-9.2 Phos-3.8# Mg-1.8
 
Brief Hospital Course:
Mr. ___ was admitted to Urology service after bipolar  
transurethral resection of prostate. No concerning 
intraoperative events occurred; please see dictated operative 
note for details. He patient received ___ antibiotic  
prophylaxis. The patient's postoperative course was complicated 
only by delayed return to baseline respiratory status. He 
received intravenous antibiotics and continuous bladder 
irrigation overnight. On POD1 the CBI was discontinued and Foley 
catheter was removed. He passed his voiding trial but as stated, 
it took two additional days of aggressive pulmonary toileting 
before he was able to maintain room air oxygen saturation at 
above 92%.  Mr. ___ to 87% on room air while 
ambulating (remained asymptomatic) however he was mobilizing 
safely and independently at the time. On room air Mr. ___ 
___ hovered around 90% for hospital days 0 to 2. He was 
noted at 95% at PREOP pre-admission testing and notes from 
Pysical therapy eval in ___ reflect room air sats, at rest, 
around 94%. Mr. ___ feels he is at his baseline. On 
discharge he was maintaining 94-95% on room air. His urine was 
clear and without clots. He remained a-febrile throughout his 
hospital stay.  At discharge, the patient had pain well 
controlled with oral pain medications, was tolerating regular 
diet, ambulating with assistance.  He was given oral pain 
medications on discharge and a course of antibiotics along with 
explicit instructions to follow up in clinic. He will resume 
visiting nurse services and home ___ on discharge home.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY 
2. Acyclovir 400 mg PO Q12H 
3. Amlodipine 10 mg PO DAILY 
4. Darunavir 600 mg PO BID 
5. Emtricitabine 200 mg PO Q24H 
6. Gabapentin 1200 mg PO BID 
7. Metoprolol Succinate XL 100 mg PO DAILY 
8. Omeprazole 20 mg PO DAILY 
9. Paroxetine 40 mg PO HS 
10. Raltegravir 400 mg PO BID 
11. RiTONAvir 100 mg PO BID 
12. LOPERamide 2 mg PO QID:PRN diarrhea 
13. Cyanocobalamin 1000 mcg IM/SC Q1MO 

 
Discharge Medications:
1. Acyclovir 400 mg PO Q12H 
2. Amlodipine 10 mg PO DAILY 
3. Darunavir 600 mg PO BID 
4. Emtricitabine 200 mg PO Q24H 
5. Finasteride 5 mg PO DAILY 
6. Gabapentin 1200 mg PO BID 
7. LOPERamide 2 mg PO QID:PRN diarrhea 
8. Metoprolol Succinate XL 100 mg PO DAILY 
9. Omeprazole 20 mg PO DAILY 
10. Paroxetine 40 mg PO HS 
11. Raltegravir 400 mg PO BID 
12. RiTONAvir 100 mg PO BID 
13. Cyanocobalamin 1000 mcg IM/SC Q1MO 
14. Acetaminophen 650 mg PO Q6H:PRN pain 
15. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain 
RX *oxycodone 5 mg Half to ONE full tablet(s) by mouth Q6hrs 
Disp #*10 Tablet Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Benign prostatic hypertrophy with incomplete bladder emptying 
requiring clean intermittent catheterization

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
-Do not lift anything heavier than a phone book (10 pounds) or 
drive until you are seen by your Urologist in follow-up

-You may continue to periodically see small amounts of blood in 
your urine--this is normal and will gradually improve

-ALWAYS follow-up with your PCP to review your post-operative 
course, medications and disposition. You will also need to 
follow up regarding your potential need of supplemental oxygen, 
especially overnight. 

     -Resume all of your pre-admission medications
     -Complete a course of antibiotics IF prescribed.
     -Colace has been prescribed to avoid post surgical 
constipation and constipation related to narcotic pain 
medication. Discontinue if loose stool or diarrhea develops. 
Colace is a stool softener, NOT a laxative

-Do not eat constipating foods for ___ weeks, drink plenty of 
fluids to keep hydrated

-No vigorous physical activity or sports for 4 weeks or until 
otherwise advised

-Tylenol should be your first line pain medication, a narcotic 
pain medication has been prescribed for breakthrough pain >4. 
Replace Tylenol with narcotic pain medication.

-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL 
sources, note that narcotic pain medication also contains 
Tylenol

-Do not drive or drink alcohol while taking narcotics and do not 
operate dangerous machinery. Also, if the Foley catheter and Leg 
Bag are in place--Do NOT drive (you may be a passenger).

If you go home with a Foley catheter:

-You will return in one week to allow more healing time and then 
you will repeat the trial of void.  DO NOT RESUME clean 
intermittent catheterization (CIC) unless advised to do so.

-You will resume your pre-admission visiting nurse services and 
home ___. Continue with regular "timed" voids to promote 
effective bladder emptying. 
 
Followup Instructions:
___

{'urinary retention': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)'], 'incomplete bladder emptying': ['Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)'], 'depression': ['Depressive disorder, not elsewhere classified'], 'dementia': ['Dementia, without behavioral disturbance'], 'B12 deficiency': ['Other B-complex deficiencies'], 'anxiety': ['Anxiety state, unspecified']}