Office Cysto (not bladder ca)

CHIEF COMPLAINT: Recurrent episodes of gross hematuria. PRIOR HISTORY: The patient has a history of microscopic hematuria for the past 6 months. He underwent a CT urogram 3 months ago that showed no evidence of malignancy or other significant abnormalities. He has no history of kidney stones or urinary tract infections. He has been referred by "Dr. Emily Carter" for further evaluation. KEY INFORMATION: - Diagnosis: Gross hematuria. - Imaging history: CT urogram (August 2024): No evidence of malignancy or other significant abnormalities. PMH, PSH, MEDS, ALLERGIES, SH, and FH: Information reviewed with patient and in EMR, with changes made where appropriate. - Medications: Tamsulosin 0.4 mg daily. - Allergies: NKDA. OFFICE CYSTOSCOPY: Indications: Gross hematuria. "After proper informed consent was obtained, and procedural time out, the flexible cystoscope was inserted per urethra into the bladder. The anterior urethra and prostate were unremarkable. The bladder was examined systematically, including scope retroflexion. Ureteral orifices were normal in size, number and location effluxing clear urine. All visible mucosa was without tumors, stones, or foreign bodies." ASSESSMENT AND PLAN: [Patient's age] 68-year-old male with a history of gross hematuria. 1. Microscopic hematuria - (N23) - Assessment: The patient presents with recurrent episodes of gross hematuria. Cystoscopy was performed and was unremarkable. - Plan: Schedule a follow-up appointment in 3 months. - Counseling: Discussed the importance of hydration and monitoring for any changes in urinary symptoms. ORDERS: No orders. FOLLOW UP: Follow-up in 3 months for repeat urinalysis and symptom review. “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”