Follow Up Clinic Note

(Write all dates in USA format ex. 6/14/2024) (Do not put in bulleted format unless instructed) (If previous session findings, or any additional information is supplied in the context tab or discussed, draw comparisons and flag any significant differences in the patient’s presentation eg. changes in key symptoms) (when using patients name use Mr. or Mrs.) CHIEF COMPLAINT 1. Frequent urination 2. Nocturia 3. Hesitancy 4. Weak urinary stream PAST UROLOGIC HISTORY 08/15/2024: Mr. Smith presented with symptoms of BPH. Started on Tamsulosin. 09/20/2024: Follow-up visit. Reported some improvement in symptoms. HPI TODAY 11/01/2024 Mr. Smith reports continued urinary frequency, nocturia, hesitancy, and a weak urinary stream. He states that his symptoms have remained relatively stable since his last visit, but he is still experiencing significant bother. He denies any new symptoms such as hematuria, incontinence, or urinary tract infections. AUA Symptom score: 18, Quality of life score: 3 PVR: 50 mL Labs: UA showed no evidence of infection. Imaging: No imaging performed. PMH, PSH, MEDS, ALLERGIES, SH, and FH: PMH: Hypertension, BPH. PSH: None. MEDS: Tamsulosin 0.4 mg daily, Lisinopril 20 mg daily. ALLERGIES: NKDA. SH: Non-smoker, drinks alcohol occasionally. FH: Father with history of prostate cancer. PHYSICAL EXAMINATION: Constitutional: AAOx3 in NAD Psychiatric: Mood and affect appropriate. Behavior cooperative. Judgment and thought content intact. GU exam: Prostate is palpably enlarged, smooth, and non-tender. LABS UA: Negative for infection. IMAGING No imaging performed. ASSESSMENT AND PLAN: 1. Frequent urination, nocturia, hesitancy, and weak urinary stream secondary to BPH. Assessment: Mr. Smith's symptoms are consistent with BPH. His AUA symptom score indicates moderate symptom severity. His PVR is slightly elevated. Plan: - Continue Tamsulosin 0.4 mg daily. - Discussed the option of adding Dutasteride to his medication regimen. Mr. Smith declined at this time due to potential side effects. - Discussed the option of a TURP procedure. Mr. Smith declined at this time. - Schedule a follow-up appointment in 3 months to reassess symptoms and PVR. 2. Hypertension Assessment: Hypertension is well-controlled on Lisinopril. Plan: - Continue Lisinopril 20 mg daily. - Monitor blood pressure at home. - No changes to current plan. 3. BPH - Assessment: BPH is stable, but symptoms are bothersome. Plan: - Continue current medication regimen. - Discussed lifestyle modifications, including limiting caffeine and alcohol intake. - Schedule a follow-up appointment in 3 months. ORDERS AND FOLLOW UP: Follow-up in 3 months for symptom assessment and PVR. Continue current medications. “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 at future visits.”