Follow Up Urology Note

CHIEF COMPLAINT: Lower urinary tract symptoms (LUTS). PAST UROLOGICAL HISTORY: Patient previously consulted at Groote Schuur Hospital in 2022 for LUTS. Diagnosed with benign prostatic hyperplasia (BPH). History of one episode of acute urinary retention requiring catheterisation in June 2023. No prior urological surgeries. Known history of prostate issues. Patient is a retired accountant. HPI TODAY 01/11/2024: Patient reports stable LUTS since the last consultation, with a slight increase in nocturia (waking 3-4 times per night compared to 2-3 times previously). Denies any new concerns, haematuria, dysuria, or fever. Patient confirms no current symptoms of infection. Summary of recent renal ultrasound from Tygerberg Hospital dated 25/10/2024: Mild prostatic enlargement with no hydronephrosis. Post-void residual (PVR) of 85ml. I personally reviewed and independently interpreted the scan and concur with findings. Lab results: Urine dipstick negative for blood, protein, and leukocytes. PSA total 3.8 ng/mL (previous 3.5 ng/mL six months ago). AUA symptom score: 17 (moderate symptoms). PVR volume post-void residual 85ml. PSA density 0.08 ng/mL/cc. PMH, PSH, MEDS, ALLERGIES, SH, and FH: - Past medical history: Hypertension, well-controlled on medication. - Past surgical history: Appendectomy (1990). - Medications: Ramipril 5mg daily, Tamsulosin 0.4mg daily, Multivitamin daily. - Allergies: Penicillin (rash). - Social history: Non-smoker, occasional social alcohol use (1-2 units per week). Lives with spouse in own home. Retired accountant. - Family history: Father had BPH. No family history of urological cancers or renal disease. PHYSICAL EXAMINATION: General appearance: Alert and oriented, appears comfortable and in no acute distress. Urological exam findings: DRE findings: Prostate enlarged, smooth, firm, non-tender, estimated 40-50g. No palpable nodules. Scrotal exam normal. No palpable bladder. ASSESSMENT AND PLAN: 68-year-old male presenting with LUTS secondary to BPH, stable on treatment with a slight worsening of nocturia. Benign Prostatic Hyperplasia (BPH) - Assessment of current status: Stable overall, but slight worsening of nocturia. Patient tolerating Tamsulosin well. - Plan: Continue Tamsulosin 0.4mg daily. Discussed potential addition of a 5-alpha reductase inhibitor if symptoms worsen significantly. Reassurance regarding PSA level and stability. - Counselling: Medication adherence, importance of fluid management in the evening, benefits and potential side effects of Tamsulosin. Discussed watchful waiting versus further medical or surgical interventions if symptoms progress. ORDERS: Laboratory tests: Repeat PSA in 6 months. FOLLOW UP: Review in urology OPD in 6 months with repeat PSA results. SHORT SUMMARY: Patient reviewed for follow-up of LUTS secondary to BPH. Remains stable on Tamsulosin, with a slight increase in nocturia. Will continue same treatment and return for PSA result in 6 months.