The SUM Program
Urology/Nephrology 
Advanced Medical Transcription

Second Edition

Developed by

	

Health Professions Institute

Modesto, California

2011

The SUM Program Urology/Nephrology 
Advanced Medical Transcription, 2nd edition

©2011, Health Professions Institute. All rights reserved.

	

Published by

Health Professions Institute
P. O. Box 801, CA 95353-0801
Telephone 209-551-2112
Fax (209) 551-0404
E-mail: hpi@hpisum.com
Web site: www.hpisum.com
Sally C. Pitman, Editor & Publisher

ISBN 978-0-9842707-6-7

Acknowledgments

	The SUM Program Urology and Nephrology unit is newly developed for inclusion in Advanced Medical Transcription, 2nd edition. It is designed to meet the growing demand for quality training in medical transcription. Providing over two hours of authentic physician dictation, the unit is designed to simulate on-the-job training within an educational framework by presenting a variety of urology and nephrology reports with variable dictating styles and regional and foreign accents.
	The reports have been carefully selected in terms of vocabulary density and subject matter,
professionally edited to delete confidential information, and sequenced in a graduated easy-to-
complex fashion for maximum learning and confidence building. They represent numerous standard
and specialized medical and surgical conditions from the vast fields of urology and nephrology.
	Forty-nine genitourinary reports are presented in this unit. They include history and physical examinations, acute care discharge summaries, consultations, and 39 operative reports detailing procedures on the genitalia, diagnostic procedures, a renal transplant, correction of urinary incontinence, transurethral resection of the urinary bladder, prostatectomy, treatments of urolithiasis, and a trauma report of a ureteral reimplantation following a crush injury. Accompanying each dictation is an accurate transcript with explanatory footnotes where indicated.
	Special features of this introduction include current scholarly articles from John H. Dirckx, M.D., on “The Kidneys: Structure, Function, Disorders,” “Prostatic Disease: Hyperplasia and Carcinoma,” and “Urolithiasis.” Guidelines specific to the transcription of genitourinary reports are provided by Ellen Drake, CMT, AHDI-F. In addition, this unit includes a new feature—Urology and Nephrology Listen Only Dictations with Transcript Keys. These reports are exceptionally challenging due to accented dictation, particularly disorganized dictators, or the necessity for extensive editing or decision-making beyond the skills of most students. The ancillary material concludes with an 820-term list, Urology and Nephrology Words and Phrases for Quick Reference.
	Heartfelt thanks go to all our editors and proofreaders as well as the many healthcare professionals who have contributed to this and many other educational products developed by Health Professions Institute since 1987.

Sally C. Pitman, M.A.
Editor and Publisher
Health Professions Institute

The SUM Program for Medical Transcription Training

Urology/Nephrology 

Advanced Medical Transcription, 2nd edition

ANCILLARY MATERIAL

	Acknowledgments by Sally C. Pitman, M.A.
	The Kidneys: Structure, Function, Disorders by John H. Dirckx, M.D.
	Prostatic Disease: Hyperplasia and Carcinoma by John H. Dirckx, M.D.
	Urolithiasis by John H. Dirckx, M.D.
	Guidelines for Transcription: Urology and Nephrology Dictation 
		by Ellen Drake, CMT, AHDI-F
	Listen Only Dictations with Transcript Keys
	Urology and Nephrology Words and Phrases for Quick Reference

TRANSCRIPT KEYS AND AUDIO FILES

HISTORY AND PHYSICAL EXAMINATION (11 minutes 13 seconds)
1. 	Obstipation. Status post gastric carcinoma. Acute cystitis. Diabetes, type 2.	Hypertension. 
	(3 minutes 25 seconds)
2. 	Gross hematuria. Anticoagulation. Hypercholesterolemia. Hypertension. Thrombocytosis. Anemia. 	(7 minutes 48 seconds)

CONSULTATION (2 minutes 3 seconds)
 3. End-stage renal disease. Flexible cystoscopy. (2 minutes 3 seconds)

DISCHARGE SUMMARY (18 minutes 45 seconds)
  4.	 Pyelonephritis with low back pain, resolved. Multiple additional diagnoses. (2 minutes 23 seconds)
  5.  Poor oral intake with recurrent renal failure and hypernatremia. History of deep venous thrombosis. 	(2 minutes 13 seconds)
  6.	Multiorgan failure with renal failure. Hyperkalemia with underlying respiratory failure.
	Diffuse coronary artery disease. Respiratory acidosis. (1 minute 40 seconds)
  7.	Postoperative left hydrocelectomy and orchiectomy. (2 minutes 5 seconds)
  8.	Status post dilation of bladder neck contracture. Transurethral resection of bladder tumor. 	Transurethral resection of the prostate. (7 minutes 57 seconds)
  9.	Stress urinary incontinence. Cystocele. TVT (tension-free vaginal tape) repair of bladder neck and 	anterior repair using a Gynemesh. (2 minutes 27 seconds)

OPERATIVE REPORTS

Procedures on the Genitalia (8 minutes 24 seconds)	 
10.		Left orchalgia. Scrotal exploration. (2 minutes 31 seconds)
11.	 Right testicular tumor. Right radical orchiectomy. (1 minute 56 seconds)
12.		Excision of penile mass. (2 minutes 36 seconds)
13.		Flexible cystoscopy. Dilation of urethral stricture. Placement of Foley catheter.
	 (1 minute 21 seconds)

Diagnostic Procedures (13 minutes 9 seconds)
14.		Right ureteral disruption. Exploratory laparotomy and psoas hitch with ureteral reimplantation.
	 (4 minutes 47 seconds)
15.		Recurrent carcinoma of the bladder. Cystourethroscopy with multiple bladder biopsies. (54 seconds)
16.	Gross hematuria with large bladder tumor. Cystourethroscopy with clot evacuation and transurethral 	resection of large papillary bladder tumor. (2 minutes 48 seconds)
17.	Hematuria, right lower quadrant pain. Cystoscopy and bilateral retrograde pyelograms. 
	(1 minute 8 seconds)
18.	Endometriosis. Cystourethroscopy, bilateral passage of ureteral catheters. (1 minute 5 seconds)
19.	Right hydronephrosis. Cystourethroscopy and removal of double-J catheter. (2 minutes 27 seconds)

Renal Transplant (1 minute 36 seconds)
20.	 End-stage renal disease. Cadaveric transplant. (1 minute 36 seconds)

Correction of Urinary Incontinence (22 minutes 54 seconds)
21.	Diagnostic laparoscopy. Laparoscopic appendectomy. Placement of a suburethral tension-free 
	vaginal tape. (5 minutes 33 seconds)
22.	Mixed urinary incontinence. Hypermobile urethra. Normal-appearing bladder. Suburethral 
	sling/Lynx. Cystoscopy. (4 minutes 14 seconds)
23.	Persistent overactive bladder. Stage 1 InterStim placement. (2 minutes 52 seconds)
24. 	Urge incontinence. Second stage InterStim implantation. (1 minute 36 seconds)
25.	Anterior colporrhaphy. Transvaginal taping and cystoscopy. Grade 3 cystocele. 
	(3 minutes 7 seconds)
26.	Laparoscopy with tubal ligation, Filshie clips, and Advantage suburethral sling. 
	(3 minutes 17 seconds)
27.	Anterior repair with transobturator sling placement. (2 minutes 15 seconds)

Transurethral Resection of Bladder, Transurethral Resection of Prostate, Prostatectomy
	(30 minutes 3 seconds)
28.	Recurrent and persistent gross hematuria secondary to benign prostatic hyperplasia. 
	Suprapubic prostatectomy. (3 minutes 42 seconds)
29.	Prostate capsular tear. Retroperitoneal exploration with closure of prostatic capsular tear and 
	closure of cystotomy. (7 minute 45 seconds)
30.	GreenLight laser ablation of prostate and transurethral resection of bladder tumor. 
	(3 minutes 2 seconds)
31.	Cystourethroscopy with bilateral retrograde pyelography and transurethral resection of large 
	bladder tumor. (2 minutes 25 seconds)
32.	Enlarged prostate with urinary retention. Simple suprapubic prostatectomy. (6 minutes 30 seconds)
33.	Repeat cystoscopy and clot evacuation. Laparotomy and repair of the bladder lesion. 
	(3 minutes 4 seconds)
34.	Urinary retention due to benign prostatic hyperplasia. GreenLight laser ablation of prostate.
	(2 minutes 12 seconds)
35.	Transurethral resection of bladder for verrucous cell carcinoma. (1 minute 23 seconds)

Treatment of Urolithiasis (28 minutes 22 seconds)
36.	Cystoscopy. Left retrograde ureteral pyelogram. Dilatation with left distal ureteral stone extraction.
	Ureteroscopy and placement of a double-J stent. (2 minutes 5 seconds)
37.	Left retrograde ureteral pyelogram. Ureteroscopy of the distal ureter. Double-J stent placement.
	(2 minutes 13 seconds)
38.	Right ureteroscopy. Holmium ablation of ureteral and renal pelvic stones. (3 minutes 13 seconds)
39.	Cystoscopy under anesthesia. Left ureteroscopy with holmium laser lithotripsy,  and 6 x 26 
	ureteral stent placement. (2 minutes 12 seconds)
40.	Cystoscopy. Left double-J stent placement. Left extracorporeal shock wave lithotripsy.
	(1 minute 58 seconds)
41.	Cystoscopy under anesthesia. Right flexible ureteroscopy. Holmium ablation of a lower pole 	calculus and a 6 x 24 ureteral stent placement after brush biopsy of the mid pole. 
	(2 minutes 51 seconds)
42.	Right kidney stone. Right extracorporeal shock wave lithotripsy. (1 minute 16 seconds)
43.	Right kidney and ureteral stones. Right extracorporeal shock wave lithotripsy. 
	(1 minute 37 seconds)
44.	Left ureteroscopy. Manipulation of stone. Stent placement. (1 minute 21 seconds)
45.	Left Flexi-Tip placement and left extracorporeal shock wave lithotripsy. (2 minutes 40 seconds)
46.	Left cystoscopy, left double-J stent placement, and left extracorporeal shock wave lithotripsy. 
	(2 minutes 50 seconds)
47.	Extracorporeal shock wave lithotripsy of left lower pole kidney stone. (51 seconds)
48.	Extracorporeal shock wave lithotripsy of right kidney stone. (2 minutes 8 seconds)

Trauma (3 minutes 1 second)
49.	Distal crush injury, right ureter. Primary ureteral reimplantation. (3 minutes 1 second)

TOTAL:  Approximately 2 hours 20 minutes of dictation