Prostatectomy Followup

SHORT SUMMARY: Mr. Smith, a 68-year-old man, presents for a follow-up after prostatectomy. He reports improved urinary continence and is managing erectile dysfunction with medication. CHIEF COMPLAINT: Mr. Smith is a 68-year-old man, presents to the office today to follow-up after prostatectomy on 06/15/2024 for T2aN0M0, Gleason 3+4=7, margin negative. He is 4 months postop. PROSTATE CANCER HISTORY: Mr. Smith was diagnosed with localized prostate cancer in March 2024 after an elevated PSA of 6.2 ng/mL. A subsequent MRI showed a suspicious lesion in the right peripheral zone. A prostate biopsy confirmed adenocarcinoma, Gleason 3+4=7. He underwent a robotic-assisted radical prostatectomy on June 15, 2024, performed by Dr. Thomas Kelly. Pathology revealed T2aN0M0, Gleason 3+4=7, with negative margins. RECOVERY MILESTONES: - Urinary continence: Achieved continence with one pad per day as of September 2024. - Urinary stream: Good urinary stream, no hesitancy or straining, as of September 2024. - Erectile function: Preop function was good. Postop function is improved with Tadalafil 5mg daily. HPI TODAY 11/01/2024: - 4 months since prostatectomy. - Reports improved urinary continence and erectile function with medication. - No new urinary symptoms. - PSA level is 0.01 ng/mL, drawn on October 25, 2024. PMH, PSH, MEDS, ALLERGIES, SH, and FH: - PMH: Hypertension, well controlled with medication. - MEDS: Tadalafil 5mg daily, Amlodipine 5mg daily. - ALLERGIES: NKDA. ASSESSMENT AND PLAN: Mr. Smith, a 68-year-old man, is 4 months post-radical prostatectomy for localized prostate cancer. He is doing well with good urinary control and improved erectile function. 1. Prostate Cancer (Prostate cancer, C61) - Assessment: PSA is undetectable. No evidence of recurrence. - Plan: Continue PSA monitoring every 6 months. - Counseling: Discussed the importance of continued follow-up and monitoring for any signs of recurrence. 2. Stress incontinence (and ICD-10 code) - Assessment: Improved continence with one pad per day. - Plan: Continue pelvic floor exercises. - Counseling: Reviewed pelvic floor exercises and discussed strategies for managing occasional leakage. 3. Erectile dysfunction (and ICD-10 code) - Assessment: Improved erectile function with Tadalafil. - Plan: Continue Tadalafil 5mg daily. - Counseling: Discussed the importance of medication adherence and potential side effects. ORDERS: PSA blood test in 6 months. FOLLOW UP: Follow up in 6 months for PSA and clinical assessment.