Bladder cancer (CYSTO) followup

SHORT SUMMARY: The patient, a 65-year-old man, attended a follow-up appointment for bladder cancer initially diagnosed in 2020. The cystoscopy showed no recurrence of tumors. CHIEF COMPLAINT: Patient presents to the office today to followup bladder cancer diagnosed 2020 for T1N0M0. NCCN risk group: Intermediate. BLADDER CANCER HISTORY: The patient was diagnosed with bladder cancer in 2020, with initial pathology showing T1N0M0. He underwent a TURBT in March 2020, which confirmed the diagnosis. Cytology in April 2020 showed atypical cells. Upper tract imaging in May 2020 was unremarkable. Intravesical therapy with BCG was administered from June to August 2020. Referred by Dr. John Smith, with urologic follow-up by Dr. Emily Brown. "KEY INFORMATION:" - Diagnosis: 2020, T1N0M0 - Cytology: - 04/2020: Atypical cells - Upper tract imaging history: - 05/2020: Unremarkable - Intravesical therapy history: - 06/2020: BCG - 07/2020: BCG - 08/2020: BCG - Other relevant information: none additional "PROCEDURE HISTORY:" 1. TURBTs and OR PROCEDURES: - TURBT/Biopsy History: - 03/2020: T1N0M0, high grade 2. OFFICE CYSTOSCOPIES: - Office cystoscopy History: - 09/2024: No recurrence - 2 months since last cystoscopy. HPI TODAY 11/01/2024: - No new changes related to bladder cancer since the last visit. - Patient reports no symptoms. - Recent imaging on 10/2024 at City Hospital was unremarkable. I personally reviewed and independently interpreted the scan and concur with findings. PMH, PSH, MEDS, ALLERGIES, SH, and FH: Information reviewed with patient and in EMR, with changes made where appropriate. - No new updates. OFFICE CYSTOSCOPY: "Indications:" Bladder cancer surveillance After proper informed consent was obtained, and procedural time out, the flexible cystoscope was inserted per urethra into the bladder. The anterior urethra and prostate were unremarkable. The bladder was examined systematically, including scope retroflexion. Ureteral orifices were normal in size, number and location effluxing clear urine. All visible mucosa was without tumors, stones, or foreign bodies. ASSESSMENT AND PLAN: The patient is a 65-year-old man with a history of T1N0M0 bladder cancer, currently in the intermediate NCCN risk group. 1. Bladder cancer (C67.9) - Assessment: No evidence of recurrence on recent cystoscopy. - Plan: Continue surveillance with cystoscopy every 3 months. - Counseling: Discussed the importance of regular follow-up and potential signs of recurrence. ORDERS: No orders. FOLLOW UP: Follow-up cystoscopy in 3 months. SHORT SUMMARY: The patient, a 65-year-old man, attended a follow-up appointment for bladder cancer initially diagnosed in 2020. The cystoscopy showed no recurrence of tumors. 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.