Followup Renal Mass

SHORT SUMMARY: "This is a 65-year-old man who presents for follow-up regarding his renal mass. The mass has shown minimal growth, and the patient remains asymptomatic." **CHIEF COMPLAINT:** Patient presents to the office today to discuss: 1. Renal mass follow-up 2. Elevated PSA levels 3. Urinary frequency **PAST UROLOGICAL HISTORY:** "Mr. Smith is a 65-year-old man with a history of a renal mass first identified two years ago. Initial CT scan showed a 3.5 cm mass in the left kidney. Follow-up MRI six months later indicated slight growth to 3.7 cm. He underwent a biopsy, which revealed a benign oncocytoma. Mr. Smith is a retired engineer who enjoys hiking and photography. He has been under the care of Dr. Thomas Taylor and Nurse Practitioner Jane Doe." **RENAL MASS HISTORY:** - 3.5 cm on CT scan, 1 March 2022 - 3.7 cm on MRI, 1 September 2022 - Growth rate: 0.1 mm/year **HPI TODAY [11/01/2024]:** - No new changes related to the renal mass. The patient reports no pain or hematuria. - Recent ultrasound on 1 October 2024 at City Hospital shows stable mass size. "I personally reviewed and independently interpreted the scan and concur with findings." - PSA level elevated at 5.2 ng/mL, with a prostate gland size of 40 cc, resulting in a PSA density of 0.13. **PMH, PSH, MEDS, ALLERGIES, SH, and FH:** - No changes in past medical history or medications. **PHYSICAL EXAMINATION:** Constitutional: Alert and oriented, no acute distress. Psychiatric: Mood and affect normal, cooperative behavior. GU exam: Not performed today. **ASSESSMENT AND PLAN:** Mr. Smith is a 65-year-old man with a stable renal mass and elevated PSA levels. 1. Renal mass (ICD-10: D41.00) - Assessment: Stable renal mass with no new symptoms. - Plan: Continue surveillance with imaging every six months. - Counseling: Discussed the benign nature of the mass and the importance of regular monitoring. 2. Elevated PSA (ICD-10: R97.20) - Assessment: Elevated PSA with low PSA density. - Plan: Repeat PSA in six months and consider urology referral if levels increase. - Counseling: Discussed potential causes of elevated PSA and monitoring strategy. 3. Urinary frequency (ICD-10: R35.0) - Assessment: Mild urinary frequency, likely related to benign prostatic hyperplasia. - Plan: Monitor symptoms and consider medication if they worsen. **ORDERS:** No orders. **FOLLOW UP:** Follow-up in six months with repeat imaging and PSA test. SHORT SUMMARY: "This is a 65-year-old man who presents for follow-up regarding his renal mass. The mass has shown minimal growth, 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.”