History and Physical Sample Report

REASON FOR ADMISSION: Urinary tract infection and fever.

CHIEF COMPLAINT: "Problems with bladder."

HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old white male with a history of urinary frequency, burning, and recent fever. His urine was loaded with white cells in the office, and he is being admitted for intravenous antibiotics. Last night, he presented to the ER and had a temperature to 102.5 degrees, then subsequently developed worsening fever. His fever ultimately broke about 2:30 in the morning with a temperature that ended at approximately 103 degrees.

PAST MEDICAL HISTORY: Significant for oral agent diabetes mellitus and hypertension.

REGULAR MEDICATIONS: Include: (1) Glucovance. (2) Avandia. (3) Zantac. (4) Tricor. (5) Zestril.

ALLERGIES: PENICILLIN (he is unsure of the reaction - he thinks it has something to do with swelling).

FAMILY HISTORY: Significant for a father who died of myocardial infarction and mother died of a stroke. He has had a previous urinary tract infection, Escherichia coli type, in 1998, with admission to the hospital then. He has not had any other hospitalizations.

SOCIAL HISTORY: He is a truck driver. He is not an abuser of alcohol or tobacco.

REVIEW OF SYSTEMS: Significant for dysuria; PSA score of only 3.

PHYSICAL EXAMINATION:
VITAL SIGNS: Recorded in nursing notes: Temperature maximum of 101.5 degrees. He is slightly hypertensive at 145/75. His pulse oximetry is normal. His pulse rate is in the low 90s. His respiratory rate is 16.
GENERAL APPEARANCE: His mood and affect are normal. He is alert and oriented x 3. He is an excellent historian.
HEAD, EYES, EARS, NOSE, AND THROAT: Examination reveals he is normocephalic, atraumatic. Extraocular movements are intact.
NECK: Supple without jugular venous distention or thyromegaly.
CHEST: Grossly clear.
HEART: Rate is regular. Peripheral pulses appear to be normal.
LYMPHATICS: He has no abnormal adenopathy in the axillary, supraclavicular, cervical, or inguinal lymph node regions.
ABDOMINAL EXAMINATION: Soft, nontender, slightly protuberant. No evidence of inguinal, umbilical, or other fascial hernias are noted.
GENITOURINARY: The testes and phallus are normal. Prostate is about 20 g in size and significantly tender on the right hand side.

LABORATORY DATA: Indicative of a white blood cell count of 13.7. Hemoglobin and platelet count are well within normal limits. Comprehensive metabolic panel reveals a normal creatinine. Urinalysis reveals white cells present. Urine culture has been sent.

 DIAGNOSTIC IMPRESSION:
1. Probable prostatitis.
2. Urinary tract infection.

PLAN: Admission. Will do non-contrast CT scan to evaluate him for possible stone. No apparent prostate abscess is present and he will be treated with intravenous antibiotics.

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