Scribe BC - UDS Cysto consult

**Procedure**: Flexible cystoscopy, Urodynamics Thank you for the referral of your 68-year-old male patient John Smith. We met today regarding urinary frequency and nocturia. **History of Present Illness:** Mr. Smith presents with a several-month history of increased urinary frequency, both during the day and at night. He reports voiding approximately every 1-2 hours during the day and waking up 3-4 times per night to urinate. He denies any urgency, dysuria, or hesitancy. His urinary stream is slightly weaker than usual, but he feels he is emptying his bladder completely. He denies any incontinence or hematuria. **Past Medical History:** Hypertension, benign prostatic hyperplasia, and hyperlipidemia. **Medications:** Tamsulosin 0.4 mg daily, Lisinopril 20 mg daily, and Atorvastatin 20 mg daily. **Allergies:** NKDA **Social History:** Mr. Smith is a retired accountant. He is a non-smoker and drinks alcohol occasionally. **Family History:** Father had prostate cancer diagnosed at age 75. **Physical Examination:** The patient appeared well in no acute distress and walks with a normal ambulatory gait. They are of normal weight. Digital rectal examination deferred today. Cystoscopy Cystoscopy revealed a slightly enlarged prostate with no obvious masses or strictures. The bladder urothelium appeared normal. There were no stones or diverticula noted. The ureteric orifices appeared normal. Sphincter function assessment was normal. Post-void residual volume measurement was 50 mL. Procedural details including patient positioning, anesthetic used, cystoscope type, and any complications: The procedure was performed with the patient in the lithotomy position under local anesthesia using a flexible cystoscope. There were no complications. Post-procedure antibiotic prophylaxis if administered: Ciprofloxacin 500mg was administered. **Investigations**: Urine analysis, PSA, and renal function tests. **Urodynamics:** Using a laborie urodynamics set up a noninvasive uroflow cystometrogram and pressure flow studies along with patch EMG electrode studies were completed. Uroflow: Voided volume 250 mL, Max flow rate 12 mL/sec, with post void residual 50 mL. The flow curve is bell-shaped and emptying was incomplete. Cystometrogram: A 7fr dual lumen urodynamics catheter was inserted per urethra. Bladder capacity was 450 mL. First sensation to void at 200 mL. Strong desire to void at 350 mL. Detrusor overactivity was not observed. Pressure flow study: Maximum detrusor pressure was 30 cm H2O at maximum flow rate. **Assessment**: Mr. Smith presents with symptoms consistent with benign prostatic hyperplasia (BPH). Urodynamic studies confirm bladder outlet obstruction. We discussed the diagnosis and treatment options, including medical management with alpha-blockers and 5-alpha-reductase inhibitors, as well as surgical options such as transurethral resection of the prostate (TURP). The risks and benefits of each option were discussed. I recommended medical management with an alpha-blocker and a 5-alpha-reductase inhibitor. **Plan**: 1. Continue Tamsulosin 0.4 mg daily. 2. Start Finasteride 5 mg daily. 3. Follow-up in 3 months to assess symptoms and repeat uroflow. 4. Schedule a follow-up appointment for 1 November 2024. "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."