04/10/_____   JOHN DOE           #00-00-0-6

John returns to discuss his Prostascint scan.  This showed, as Dr.

Hanke’s note above, likely metastatic disease of the left ileac nodal

area.  His PSA is really minimally elevated, was 1.8 and is now 1.6.

He is asymptomatic.  We discussed options of watchful waiting,

radiation therapy, i.e., external beam or hormonal therapy.  I think

our best option is to consider radiation and thus have arranged a

consultation with radiation therapy.  I would like to see the patient

upon completion of radiation if they wish to treat, and if he does

not wish to treat he is to come back and we will talk about further

options.  Likely will choose watchful waiting for the time being.

                                    ___________, M.D./ht:___

10/10/________   JIM DOE         #00-00-12-0

(LETTER:  Dr. Bob Peterson)

  CHIEF COMPLAINT:  Urinary frequency in the afternoon.

  Arthur and his wife are seen today ahead of their scheduled May appointment.  Art states in the afternoons when he drinks water he has urinary frequency every one to two hours.  In the morning he holds back on water and does well.  At night he has nocturia times one.  He is having some dribbling or dampness in his shorts at night.  He finds he voids better when he stands.  They are worried about holding back on fluids.  He has had no pain.  He works every morning for half days at the Garst plant in Slater in their experimental station.  REVIEW OF SYSTEMS:  He denies chest pain, respiratory, or GI complaints.

PHYSICAL EXAMINATION: He walks with a slight limp.  Note, he has severe degenerative arthritis.  The bladder appears slightly fluctuant and likely distended somewhat.  He has a right inguinal hernia.  Penis is uncircumcised.  Testes are descended with a hydrocele, mild, on the right.  Rectal shows good tone, no hemorrhoids, 1+ prostate.  His urinalysis is chem and micro clear. A KUB is unchanged from the one of six months ago.  There is a suggestion of possible densities in the lower ureter area.

DISCUSSION:  In light of a normal urinalysis, no pain, ability to work where he just got a $2.00 per hour raise, and symptoms only bothering him in the afternoon when he seems up and drinks more, we mutually agree that we will leave this to watchful waiting as it is not that severe.  I do consider he is not emptying his bladder. He may need a TUR and a cystoscopy with retrograde with possible stone fragments in the lower ureter.  However, Art is not anxious for any surgical intervention at this time and with the clear urine will agree with watchful waiting.  He is to drink fluids at needed. He will see me in about nine months for a follow-up.  If voiding symptoms worsen he is a candidate for a cystoscopy with retrogrades and possible left stone extraction or TUR.

                                  ___________, M.D./ht:___

05/__/____   JANE DOE            #88-88-88-8

CHIEF COMPLAINT:  Right reflux worsening.

   This 19-month-old child was seen in my office for a consultation per Dr.

   Foster on 08/08/______ with a chief complaint of urinary tract infection and  

   a  persistent and worsening right ureteral reflux, moderate, with mild

   hydronephrosis on the right.  The child had developed

intermittent fevers and temperature at approximately six months

of age which lead to the ultimate diagnosis of urinary tract

infection. A voiding cystogram showed mild reflux on the right

at that time. She was placed on suppressive antibiotics after

initial aggressive treatment.  She had a follow-up voiding

cystogram on 03/31/2000 which showed a worsening reflux situation

on the right with a moderate hydroureteronephrosis.  She has had

no breakthrough infections.  She was seen by Dr. Foster

and referred to me for a consultation.  Both parents accompany

the child.  There are three other children of mixed marriages

and the couple is currently separated.  The mother is a RN and

the father works in sales.  They were prepared for potential

surgery as discussed by Dr. Foster.  PAST HISTORY:  OPERATIONS

-       None.  ILLNESS - None.  MEDICATIONS - Gantrisin once daily.

SOCIAL HISTORY - As mentioned, father works in sales.  The

parents are separated.  There are three other mixed marriage

siblings, but this is the only child of this couple together.  The mother is a nurse, currently unemployed.

PHYSICAL EXAMINATION: She is a healthy appearing, vibrant, young pediatric child with earrings.  The bladder is not distended.  The abdomen is thin.  Extremities are negative.

DISPOSITION:  I reviewed the x-rays personally and reviewed them with both parents showing the right reflux and a somewhat elongated bladder.  Because the reflux has definitely worsened, ureter is more dilated, ureter more hydronephrotic, I think ultimate surgery is going to be recommended and only on the right side as two voiding cystograms have shown the problem only on the right.  Because the mother is currently not working she prefers to proceed now, and thus looking at the schedule we have reserved 04/12/2000.  I discussed the expected 90-95% high success rate of a Leadbetter-Politano type surgery.  I described the method of creating an intramural tunnel.  I described the risk of possible stenosis that could ultimately lead to re-surgery.  All questions were answered and we have scheduled this with a preoperative exam by Dr. Foster.

                                    ___________, M.D./ht:___

04/04/____   JOE DOE             #00-00-00-8

CHIEF COMPLAINT:  Yearly prostate check.

This 60-year-old male is deaf and mute and communicates by writing.

He brings with him a five page Internet printout of prostate disorders

of which he has answered the questions.  He states he had a PSA and

it was 6.0, but I do not have that actual data.  I reviewed the previous

typed note and reviewed it with him showing it has been a slow, steady

rise.  In February of 1999 he had biopsy that was benign.  His current

problems are:  1) He does have dripping and wears a pad which he

does not like and requests if there is any medication to fix it.

2) I note the slight rise in his PSA.  REVIEW OF SYSTEMS:  He denies

chest, respiratory complaints.  GI - He states he has changed his diet where he is eating only "legumes".  Although difficult to communicate, he thought that this might help his prostate trouble.

PHYSICAL EXAMINATION: He is a tall male.  Neck without nodes or mass. Abdomen is

nondistended.  Penis is normal and uncircumcised.  Testes are descended.  Rectal

is 1 to 2+, benign, boggy with good tone. Extremities are negative.  Urinalysis,

_________ test, is negative.

IMPRESSION: Benign prostatic hypertrophy by feel and proven on biopsy a year ago

with a slight rise in PSA. 

I tried to discuss this with him by circling and noting the slight rise.  However,

with a biopsy within a year being benign I am going to carefully watch, repeat a

PSA, and see in one year.  If there is a significant rise again he could have

another biopsy.  I do not think the diet is effecting or improving anything

regarding the urinary tract. 

             ___________, M.D./ht:___

09/09/_______   JOHN DOE         #00-00-20-0

(COPY:  Dr. Johnson)

Charles and his wife are here for follow-up of his bladder cancer.

He has no interval history of bleeding, pain, fever, or chills. 

However, he has had continued weight loss and has had major problems

with his diabetes.  As such, he is currently on insulin.  He states

his sugars have dropped from 300 to the 70-range. 

A flexible cystoscopy performed showed a resected prostate which

is open.  The bladder itself is trabeculated, grade II-III, with

wide cellules, but careful inspection showed no evidence of tumor

or other defect other than mentioned.  Slit-like orifices were noted.

I have recommended a cystoscopy in one year.  Cipro 250 mg was given.

I will see in a year and he may return to Dr. Laxson for continued

medical follow-up.

                                    ___________, M.D./ht:___

04/04/____   JANE DOE            #00-00-0-1

CHIEF COMPLAINT:  Urgency, frequency, especially at night.

I reviewed my notes from last fall with Jane.  She is accompanied

by her daughter.  Jane can given no reliable history, but through

the daughter her major problem is that she is now at home living

with her husband, where her husband who is also ill, is up with her

80% of the time at night taking her to the bathroom with this feeling

of urgency and frequency.  She has been seen recently by Dr. McGee.

They changed her medication by adding Comtan for her Parkinson. 

They think things are somewhat better.  She is also on Sinemet,

Florinef, calcium, levodopa, and vitamins.  She has had two infections

the past four months and these seem to cause her to feel tired and

weak, but otherwise stable.

PHYSICAL EXAMINATION: The patient has Parkinson, very weak.  As mentioned, she

does not speak.  The bladder is not distended.  Her urinalysis is orange stained. 

They think from the Comtan, but chem and micro negative.

I am recommending a trial of Macrodantin 50 mg daily x 50 to prevent

infections.  2) I gave them samples of Detrol 2 mg to take h.s.

If this works and she has less frequency a prescription for #50 to use once a

night was given.  They are to check with me p.r.n.

                                    ___________, M.D./ht:___

04/09/______   JACK DOE          #00-00-0-0

  (COPY:  Dr. White)

CHIEF COMPLAINT:  Suspicious right prostate.

This is a 72-year-old male.  I have seen this patient in 1985 and

reviewed that note.  Dr. White did a physical after the patient

developed a head cold and noted slow urination.  Rectal showed a

suspicious right prostate mass.  He had a PSA of 1.5.  The patient

states his symptoms have improved, his cold improved, and he no longer

is as bad.  He does remember having had a cystoscopy 15 years ago.

He has no fevers, chills, or dysuria.  Weight and appetite are stable.

Dr. White’s note was reviewed and I will not reiterate.  PAST HISTORY:

OPERATIONS - Gallbladder, back, sinus surgery recently.  MEDICATIONS

- None.  SOCIAL HISTORY - He is accompanied by his wife.  He is a

retired mechanic and farm salesman. 

PHYSICAL EXAMINATION: He is a pleasant male of stated age.  Neck

without nodes, mass, or thyroid.  Respirations are clear.  Inguinal

without hernia.  Abdomen is negative.  Rectal is 2+, benign, but

there is a slight gritty feeling of the right base.  My cystoscopy

note did show some prostatic calculi years ago and this certainly

could be compatible now.  Testes, epididymis are normal.  Neuropsych

is oriented times three.

IMPRESSION: Suspicious prostate with a normal PSA at 1.5 and

hemoglobin of 12.0.  Because of the suspicion I am recommending an

ultrasound with biopsy which we have scheduled.

             ___________, M.D./ht:___