Office cysto (STENT REMOVAL)

CHIEF COMPLAINT: Patient presents to the office today for cystoscopy and left stent removal. PRIOR HISTORY: Patient is a 68-year-old male with a history of gross hematuria and left flank pain. He underwent a left ureteroscopy with stent placement on 10/15/2024 for a 1.5 cm upper ureteral stone. Pathology from the stone was consistent with calcium oxalate. The referring physician was Dr. Emily Carter. KEY INFORMATION: - Prior procedure: Left ureteroscopy with stent placement for a 1.5 cm upper ureteral stone. PMH, PSH, MEDS, ALLERGIES, SH, and FH: Information reviewed with patient and in EMR, with changes made where appropriate. - Updated PMH: Hypertension, Hyperlipidemia, Benign Prostatic Hyperplasia. - Updated PSH: Appendectomy at age 10. - Updated medications: Amlodipine 5mg daily, Atorvastatin 20mg daily, Tamsulosin 0.4mg daily. - Updated allergies: NKDA. - Updated social history: Non-smoker, occasional alcohol use. - Updated family history: Father with prostate cancer. OFFICE CYSTOSCOPY AND STENT REMOVAL: Indications: Left ureteral stent removal following ureteroscopy for a left upper ureteral stone. After proper informed consent was obtained, and procedural time out performed, the flexible cystoscope was inserted per urethra into the bladder. The anterior urethra and prostate were unremarkable. The distal coil of the left ureteral stent was visualised, grasped, and removed intact without difficulty. ANTIBIOTICS: Ciprofloxacin 500mg was given x 1. ASSESSMENT AND PLAN: Patient is a 68-year-old male who underwent successful left ureteral stent removal today. He is doing well post-procedure. 1. Left Ureteral Stone (ICD-10 code: N20.1) - Assessment: Stone successfully removed with prior ureteroscopy. No evidence of residual stone. - Plan: Patient instructed to increase fluid intake. Follow-up in 2 weeks. - Counseling: Discussed the importance of hydration to prevent future stone formation. 2. Benign Prostatic Hyperplasia (ICD-10 code: N40.0) - Assessment: Stable on Tamsulosin. - Plan: Continue Tamsulosin 0.4mg daily. - Counseling: Discussed the importance of medication adherence. ORDERS: Ciprofloxacin 500mg x 3 days. FOLLOW UP: Follow up in 2 weeks for a routine check-up. SHORT SUMMARY: Patient underwent successful left ureteral stent removal today. He is doing well and will follow up in two weeks. 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.