**Motif de consultation:**
- Le patient se présente pour une consultation en raison d'une augmentation de la fréquence urinaire et d'une sensation d'urgence depuis environ deux mois. Il rapporte également des épisodes occasionnels de nycturie (se lever la nuit pour uriner).
**Histoire de la maladie, antécédents, traitements:**
- Le patient décrit l'apparition progressive des symptômes, sans facteur déclenchant clair. Il n'y a pas de douleur associée. Il a essayé de boire moins de liquides le soir, mais cela n'a pas amélioré les symptômes. Il n'a pas d'antécédents de problèmes urinaires.
- Antécédents médicaux : Hypertension artérielle, bien contrôlée avec des médicaments.
- Antécédents chirurgicaux : Appendicectomie il y a 20 ans.
- Médicaments actuels : Lisinopril 10 mg une fois par jour.
- Antécédents sociaux : Non-fumeur, consommation modérée d'alcool (2 verres par semaine). Profession : Comptable.
- Allergies : Pas d'allergies connues.
**Constations:**
- Constantes : TA : 130/80 mmHg, FC : 72 bpm, SatO2 : 98% sur air ambiant, Température : 37°C.
- Examen général : Le patient est éveillé, alerte et orienté. Pas de signes de détresse.
- Examen physique : Examen abdominal : Souple, non sensible. Examen génital : Pas de masses palpables. Prostate : Légèrement augmentée de volume, consistance ferme, non douloureuse à la palpation.
- Autres examens : RAS.
- Examens complémentaires : Analyse d'urine : Légèrement trouble, pas de nitrites, quelques leucocytes. PSA : 2.5 ng/mL.
**Conclusion, projet et propositions thérapeutiques:**
[1. Hypertrophie bénigne de la prostate (HBP)]
- Évaluation : Les symptômes du patient, combinés à l'examen physique et aux résultats du PSA, suggèrent une HBP.
- Diagnostic différentiel : Infection urinaire, cancer de la prostate.
- Examens prévus : Surveillance du PSA, suivi des symptômes.
- Traitement médical : Tamsulosine 0.4 mg une fois par jour pour soulager les symptômes.
- Modifications du mode de vie : Réduire la consommation de liquides le soir, éviter la caféine et l'alcool.
- Rendez-vous de suivi : Revoir le patient dans trois mois pour évaluer la réponse au traitement et surveiller les symptômes.
**Remarques complémentaires:**
- Le patient a été informé de la nature de l'HBP, des options de traitement et des effets secondaires potentiels.
- Instructions : Surveiller les symptômes et consulter en cas de rétention urinaire aiguë ou d'infection urinaire.
- Préoccupations : Le patient est préoccupé par la possibilité d'un cancer de la prostate. Il a été rassuré sur le fait que son PSA est dans la plage normale.
- Accompagnement : Le patient était accompagné de son épouse.
**Motif de consultation:**
- [Reason(s) for consultation, including specific urological concerns or symptoms such as urinary frequency, urgency, incontinence, hematuria, pain in the pelvic area, erectile dysfunction, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences and insert direct patient quotes only if they are explicitly present in the transcript.)
**Histoire de la maladie, antécédents, traitements:**
- [Detailed history of the presenting complaint(s), including onset, duration, severity, pattern of symptoms, aggravating/alleviating factors, associated symptoms, any previous treatments/surgeries and responses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences and insert direct patient quotes only if explicitly mentioned.)
- [Past medical and surgical history, highlighting any previous urological diagnoses, interventions, hospitalizations, outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current medications, including any medications for urological conditions, over-the-counter medications, supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Social history, focusing on lifestyle factors such as fluid intake, smoking, alcohol use, sexual history, occupation, any exposure to chemicals or irritants] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergies, including allergies to medications, latex, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Constations:**
- [Vitals, including BP, HR, oxygen saturation, temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [General examination findings such as pallor, icterus, lymphadenopathy, pedal edema] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical examination findings focusing on urological examination assessing abdominal, genital, rectal areas (in men, prostate examination; in women, pelvic examination), any palpable masses, tenderness or abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical examination findings focussing on examination of other systems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations with results, including laboratory tests, imaging studies, urodynamic tests, cystoscopy findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Conclusion, projet et propositions thérapeutiques:**
[1. Urological Issue or Condition]
- [Assessment, including the likely diagnosis and rationale based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations planned, including any further imaging, biopsy, urodynamic testing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medical treatment planned, detailing medications, dosage, expected outcomes, potential side effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Surgical options considered, including surgery details such as type of surgery, alternative options, expected outcomes, potential risks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Lifestyle modifications, including dietary advice, fluid intake recommendations, pelvic floor exercises] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mention any referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[2. Additional Urological Issues or Conditions]
- [Follow the same structure as above for each additional issue or condition identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Remarques complémentaires:**
- [Patient education on the diagnosed condition(s), including explanation of urological health, potential complications, and the importance of treatment adherence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Instructions for monitoring and managing symptoms, including when to seek urgent care for acute issues such as severe pain, inability to urinate, or signs of infection] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any specific patient or family concerns addressed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Designation of any person accompanying during the consultation (e.g., wife, husband, child)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [In the case of gynecological, external genital or rectal examinations, specify that the patient has authorized the examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit section entirely. Never come up with your own assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Insert direct patient quotes only if they are explicitly present in the transcript. Use as many lines, paragraphs, or bullet points as needed to capture all relevant clinical information.)