Followup Urology Note (Elevated PSA)

CHIEF COMPLAINT: Patient presents to the office today to discuss: 1. Elevated PSA 2. Urinary frequency 3. Nocturia PAST UROLOGICAL HISTORY: Mr. Smith, a 68-year-old man, has a history of benign prostatic hyperplasia (BPH) diagnosed five years ago. He has been managed with tamsulosin 0.4 mg daily. He underwent a transurethral resection of the prostate (TURP) two years ago due to urinary retention. Post-operatively, his symptoms improved significantly. He is a retired accountant and enjoys gardening. PSA HISTORY: - 03/15/2024 – PSA 4.2 ng/mL - 09/20/2024 – PSA 5.8 ng/mL PSA density calculated by dividing most recent PSA by last known prostate size: 0.12 PROSTATE BIOPSY HISTORY: 06/18/2021 – 12-core biopsy – benign HPI TODAY 11/01/2024: Patient reports a gradual increase in urinary frequency over the past three months, now voiding every 2 hours during the day. He also reports nocturia twice per night. He denies any hematuria, dysuria, or urinary incontinence. He states, “I’m worried about my PSA rising again.” Relevant imaging results with date, location, and interpretation. Use the phrase: “I personally reviewed and independently interpreted the scan and concur with findings.”: Abdominal CT scan performed on 09/20/2024 showed no evidence of metastatic disease. I personally reviewed and independently interpreted the scan and concur with findings. Relevant test results with interpretation: Repeat PSA 5.8 ng/mL. AUA Symptom Score: 18 PVR result: 30 mL PSA density (PSA/prostate size): 0.12 PMH, PSH, MEDS, ALLERGIES, SH, and FH: - Updated PMH items: Hypertension, BPH - Updated PSH items: TURP - Current or updated medications: Tamsulosin 0.4 mg daily, Lisinopril 20 mg daily - Allergies: NKDA - Updated social history, e.g. smoking, alcohol, marital status: Non-smoker, occasional alcohol use, married. - Updated family history: Father had prostate cancer diagnosed at age 75. PHYSICAL EXAMINATION: Constitutional: General appearance and state of distress. Level of consciousness: Well-appearing male in no acute distress. GU exam findings: Prostate exam reveals a moderately enlarged prostate, smooth, with no nodules or areas of induration. ASSESSMENT AND PLAN: Mr. Smith, a 68-year-old man, presents with an elevated PSA and worsening lower urinary tract symptoms. The current assessment indicates a possible recurrence of BPH and the need to rule out prostate cancer. 1. Elevated PSA (N42.9) - Assessment: Elevated PSA concerning for possible prostate cancer or BPH progression. - Plan: Discussed the risks and benefits of prostate biopsy. Patient agreed to proceed with a repeat 12-core prostate biopsy. Biopsy scheduled for 11/15/2024. - Counseling: Discussed the natural history of prostate cancer and BPH, including management options and the importance of shared decision-making. 2. BPH (N40) - Assessment: Worsening lower urinary tract symptoms consistent with BPH. - Plan: Continue Tamsulosin 0.4 mg daily. Schedule follow-up in 3 months. - Counseling: Reviewed the benefits and risks of tamsulosin, including potential side effects. Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to continue Tamsulosin 0.4 mg daily based on patient’s condition and response to treatment. ORDERS: - PSA - Repeat 12-core prostate biopsy FOLLOW UP: Follow up in 3 months to review biopsy results and assess symptom control. SHORT SUMMARY: A 68-year-old man with elevated PSA and BPH symptoms. A repeat prostate biopsy was ordered and scheduled. “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.”