**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."
**Procedure**: Flexible cystoscopy, Urodynamics
Thank you for the referral of your [patient's age, patient's gender] patient [patient's first name]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) We met today regarding [patient's chief complaint]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**History of Present Illness:**
[describe current issues, symptoms, duration, and any relevant details as they relate to the reason for referral, including details from the contextual notes associated with the abbreviation HPI] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences. Do not use point form.)
[discuss urinary symptoms in terms of frequency of voids, presence/absence of urgency, number of voids per night, presence/absence of dysuria, strength of urinary stream, presence/absence of complete bladder emptying, presence/absence of straining to void, presence/absence of intermittent urinary stream] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[mention if the patient complains of pain, noting the location and other details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[mention if the patient complains of gross hematuria] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[mention if the patient has recurrent UTIs, noting the frequency and severity of infections] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Past Medical History:**
[describe past medical history, previous surgeries, including details from the contextual notes associated with the abbreviation PMH] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. List diagnoses and procedures in a list without line breaks, separated by commas.)
**Medications:**
[mention current medications and herbal supplements, including details from the contextual notes associated with the abbreviation Meds] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a list.)
**Allergies:**
[mention known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. If no allergies to medications, state "NKDA".)
**Social History:**
[describe social history, including smoking, alcohol use, and occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Family History:**
[mention family medical history relevant to genitourinary malignancy, particularly prostate cancer in first or second-degree relatives; cancer of the breast, pancreas or ovary in first or second-degree relatives; and cancer of the colon, stomach and endometrium in first- or second-degree relatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Physical Examination:**
[describe findings from physical examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
The patient appeared well in no acute distress and walks with a normal ambulatory gait. They are of normal weight. [Digital rectal examination, or female pelvic examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) deferred today.
Cystoscopy
[Cystoscopy findings including urethral appearance, bladder urothelium condition, presence/absence of tumors, stones, diverticula, inflammatory changes, ureteric orifice position and appearance, sphincter function assessment, and post-void residual volume measurement] (Only include if cystoscopy was performed and explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Document all findings as observed during the procedure.) [Procedural details including patient positioning, anesthetic used, cystoscope type, and any complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) [Post-procedure antibiotic prophylaxis if administered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
**Investigations**:
[mention any investigations ordered or reviewed, including lab tests, imaging, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a list.)
**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 [voided volume], Max flow rate [max flow rate], with post void residual [PVR]. The flow curve [describe flow curve] and emptying was [complete, incomplete, markedly elevated PVR]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
Cystometrogram:
A 7fr dual lumen urodynamics catheter was inserted per urethra. [cystometrogram details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pressure flow study:
[pressure flow study details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Assessment**:
[provide assessment, including a description of the discussion of the diagnosis and treatment options; briefly discuss the risks and benefits of different treatment options if mentioned; and include rationalizations for treatment recommendations if discussed explicitly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Plan**:
[outline the management plan, including medications, procedures, follow-up, and referrals, using very brief, succinct language and avoiding rationales for treatment options] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Format as a numbered list of tasks.)
"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."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
