Followup Renal Cyst

SHORT SUMMARY: "This is a 65-year-old man who presents for follow-up regarding his renal cyst. The cyst has shown no significant changes, and the patient remains asymptomatic." **CHIEF COMPLAINT:** Patient presents to the office today to discuss: 1. Follow-up on renal cyst 2. Review of recent imaging results 3. Discussion of any new symptoms **PAST UROLOGICAL HISTORY:** "Mr. Smith is a 65-year-old man with a history of a renal cyst first identified two years ago. Initial ultrasound showed a Bosniak IIF cyst measuring 3.5 cm. Follow-up CT scans have shown stable size and characteristics. He underwent a cystoscopy last year, which was unremarkable. Mr. Smith is a retired engineer who enjoys hiking and photography. He has been under the care of Dr. Thomas Kelly." **RENAL CYST HISTORY:** - Bosniak IIF classification, CT scan on 15 March 2023, cyst size 3.5 cm, stable characteristics. - Prior plan: Continue monitoring with annual imaging and follow-up visits. **HPI TODAY [11/01/2024]:** - No new changes related to the renal cyst. The patient reports no pain or hematuria. - Recent ultrasound on 1 October 2024 at City Hospital shows no change in cyst size or features. I personally reviewed and independently interpreted the scan and concur with findings. **PMH, PSH, MEDS, ALLERGIES, SH, and FH:** - No changes in PMH, PSH, MEDS, ALLERGIES, SH, and FH since last visit. **PHYSICAL EXAMINATION:** Constitutional: Alert and oriented, no acute distress. Psychiatric: Mood and affect appropriate, cooperative behavior. GU exam: Not performed today. **ASSESSMENT AND PLAN:** 65-year-old man with a stable Bosniak IIF renal cyst. 1. Renal cyst (N28.1) - Assessment: Stable Bosniak IIF cyst with no new symptoms. - Plan: Continue annual imaging and follow-up. Next ultrasound in one year. - Counseling: Discussed the benign nature of the cyst and the importance of regular monitoring. **ORDERS:** No orders. **FOLLOW UP:** Follow-up in one year with repeat ultrasound. SHORT SUMMARY: "This is a 65-year-old man who presents for follow-up regarding his renal cyst. The cyst has shown no significant changes, and the patient remains asymptomatic." “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.”