Urology - New Patient Note

The patient is a 58-year-old male presenting with new-onset urinary frequency and urgency. The patient is accompanied by his wife, who is providing additional historical details. **Past Medical History:** Benign Prostatic Hyperplasia (BPH) diagnosed 5 years ago, well-controlled hypertension, hyperlipidaemia **Past Surgical History:** Appendectomy (1995), laparoscopic hernia repair (2010) **External Medications:** Tamsulosin 0.4mg daily, Lisinopril 10mg daily, Atorvastatin 20mg daily, Vitamin D supplement **Known Allergies:** Penicillin (hives), environmental (dust mites) **Lifestyle Notes:** Social alcohol use (2-3 units/week), married with two adult children, retired accountant, non-smoker for 15 years **Family History:** Father with prostate cancer (diagnosed at 70), mother with type 2 diabetes **History of Present Illness:** Mr. John Doe presents with a 3-month history of increased urinary frequency, urgency, and nocturia (waking 3-4 times per night to urinate). He reports occasional weak stream and a sensation of incomplete bladder emptying. Symptoms have gradually worsened, impacting his sleep and daily activities. He denies dysuria, hematuria, or fever. He has not tried any new medications recently and reports stable fluid intake. Previous treatments for his BPH have included watchful waiting and lifestyle modifications, but symptoms are now more bothersome. **Physical Exam:** Abdomen soft, non-tender, no organomegaly. External genitalia unremarkable. Digital Rectal Exam (DRE) reveals a moderately enlarged, smooth prostate with no suspicious nodules or tenderness. **Tests/US Reports:** Recent urinalysis (1 November 2024) negative for infection. Renal ultrasound (1 November 2024) shows mild bilateral hydronephrosis and a post-void residual volume of 150ml, indicating significant bladder outlet obstruction. PSA level (1 November 2024) 4.2 ng/mL. **Impression & Plan:** The clinical impression is Benign Prostatic Hyperplasia with acute worsening of lower urinary tract symptoms, complicated by bladder outlet obstruction and mild hydronephrosis. Given the worsening symptoms and objective findings, a more aggressive management plan is indicated. We will initiate Finasteride 5mg daily in addition to his current Tamsulosin to address prostate volume. The patient will be counselled on lifestyle modifications, including reduced evening fluid intake and avoiding bladder irritants. We will discuss the potential benefits and risks of surgical interventions, specifically Transurethral Resection of the Prostate (TURP), as a definitive treatment option. He will be referred for a flow rate study and urodynamic assessment. Follow-up is scheduled in 6 weeks to assess symptom improvement and discuss further management, including surgical options if medical therapy is insufficient.