CaP Active Surveillance

SHORT SUMMARY: The patient, a 65-year-old man, visited today for a follow-up on his prostate cancer, which is under active surveillance. His condition remains stable with no significant changes since the last visit. CHIEF COMPLAINT: "Patient presents to the office today to follow up prostate cancer on active surveillance diagnosed in 2020 for T1c, Gleason score 6 (3+3)." PROSTATE CANCER HISTORY: The patient was diagnosed with prostate cancer in 2020, with a Gleason score of 6 (3+3) and a PSA level of 4.5 ng/mL. Initial biopsy showed 2 out of 12 cores positive with 10% involvement. Last PSA was 4.8 ng/mL, and prostate size was 40 cc, resulting in a PSA density of 0.12. MRI in March 2023 showed a stable PIRADS 2 lesion. Referred by Dr. John Smith, with urologic follow-up by Dr. Emily Brown. KEY INFORMATION: - Diagnosis: 2020, Gleason score 6 (3+3), PSA 4.5 ng/mL - Biopsy History: March 2020, prostate size 40 cc, Gleason score 6 (3+3), 2/12 cores positive - MRI History: March 2023, stable PIRADS 2 lesion - Genomics history: not known - PSAD: 0.12 - PSA Range: PSA has ranged between 4.5 and 5.0 ng/mL over 2020-2024 - Last DRE: Last DRE 1 November 2024 showed no abnormalities - Tentative plan: Next biopsy planned for March 2025 HPI TODAY [11/01/2024]: - No new changes related to the prostate cancer condition since the last visit. - No current symptoms reported. - MRI from March 2023 reviewed, showing stable PIRADS 2 lesion. I personally reviewed and independently interpreted the scan and concur with findings. - PSAD: 0.12 PMH, PSH, MEDS, ALLERGIES, SH, and FH: - No changes reported. PHYSICAL EXAMINATION: Constitutional: Appears well, no distress. Alert and oriented. Psychiatric: Mood and affect normal. Cooperative behavior. GU exam: Not performed today. ASSESSMENT AND PLAN: The patient is a 65-year-old man with prostate cancer on active surveillance, Gleason score 6 (3+3), NCCN low-risk group. 1. Prostate Cancer (C61) - Assessment: Stable condition, no progression noted. - Plan: Continue active surveillance, next biopsy in March 2025. - Counseling: Discussed the natural history of low-risk prostate cancer and the benefits of active surveillance. ORDERS: No orders. FOLLOW UP: Follow-up in 6 months with repeat PSA test. FUTURE CONSIDERATIONS: As above, no further considerations based on current literature. SHORT SUMMARY: The patient, a 65-year-old man, visited today for a follow-up on his prostate cancer, which is under active surveillance. His condition remains stable with no significant changes since the last visit. 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.