**PROBLEM LIST:**
1. Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms (LUTS).
2. Elevated PSA.
- PSA: 6.2 ng/mL (most recent), 5.8 ng/mL (prior).
**MANAGEMENT PLAN:**
- Continue Tamsulosin 0.4mg daily.
- Schedule repeat PSA in 3 months.
- Discussed the option of a TURP procedure if symptoms worsen.
**Past Medical History:**
- Hypertension.
- Hyperlipidemia.
**Prior Abdominal Surgical History:**
- Appendectomy, 1998.
**Occupation:**
The patient is a retired accountant.
**CONSULTATION NOTES:**
It was a pleasure to see John today.
John presented today with worsening urinary frequency, nocturia (3-4 times per night), and hesitancy. He reports these symptoms have been gradually worsening over the past six months. He denies any hematuria, incontinence, or significant pain. He has a family history of prostate cancer (father). He has been taking Tamsulosin for the past year with some initial improvement, but now reports a decline in efficacy.
Ultrasound of the prostate performed 6 months ago showed an enlarged prostate with no evidence of malignancy. No other imaging was performed today.
PSA was checked today and the result was 6.2 ng/mL. The patient's previous PSA was 5.8 ng/mL.
**PHYSICAL EXAMINATION:**
Digital rectal examination revealed an enlarged, smooth prostate. No nodules were palpated. No tenderness was elicited.
**ASSESSMENT:**
Mr. Smith presents with symptomatic BPH, with a rising PSA. The patient's symptoms are not adequately controlled with current medical management. The patient is aware of the risks and benefits of further treatment options.
**PLAN:**
- Continue Tamsulosin 0.4mg daily.
- Schedule repeat PSA in 3 months.
- Discussed the option of a TURP procedure if symptoms worsen.
- Schedule follow-up appointment in 3 months.
Date: 1 November 2024
**PROBLEM LIST:**
[Summarise the main urological complaints or issues being addressed in this consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as a numbered list starting from 1.)
[PSA values if mentioned, including most recent and any prior comparative values] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as a separate bullet point using "-".)
**MANAGEMENT PLAN:**
[Summarise key planned management actions or decisions arising from today’s consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points using "-" and place each item on a new line.)
**Past Medical History:**
[Relevant past medical history, including comorbidities mentioned in this or prior letters] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points using "-" and place each item on a new line.)
**Prior Abdominal Surgical History:**
[Details of prior abdominal surgeries, including type and approximate timing if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points using "-" and place each item on a new line.)
**Occupation:**
[Patient's occupation or employment status] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as a single sentence.)
**CONSULTATION NOTES:**
It was a pleasure to see [patient's first name] today.
[Summary of today's consultation including symptoms, frequency/severity, and relevant background history related to the current urologic presentation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form using full sentences.)
[Relevant imaging findings including modality, date, and interpretation relevant to today’s consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form using full sentences.)
[Relevant pathology or test results including date and interpretation if pertinent to the clinical context] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form using full sentences.)
**PHYSICAL EXAMINATION:**
[Findings from any physical examination including genitourinary inspection, palpation, or DRE if performed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as brief paragraph or in line-by-line format.)
**ASSESSMENT:**
[Summary paragraph outlining the main problem, clinical and imaging findings, and treatment options discussed with the patient] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as a single paragraph of 3–5 full sentences.)
**PLAN:**
[Summarise next steps including further investigations, treatment plans, referrals, and follow-up schedule] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points using "-" and place each item on a new line.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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 section blank. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)