Patient presents with [chief complaint related to urothelial carcinoma, e.g., hematuria, dysuria, flank pain].  Review of systems reveals [positive and pertinent negative findings related to urothelial carcinoma, e.g., frequency, urgency, nocturia, weight loss, abdominal pain, no fever].  Past medical history includes [relevant medical history, e.g., hypertension, diabetes, smoking history, prior bladder cancer].  Family history is significant for [relevant family history, e.g., bladder cancer, kidney cancer].  Physical examination reveals [relevant physical exam findings, e.g., palpable abdominal mass, costovertebral angle tenderness, normal genital exam].  Based on patient presentation and risk factors, the differential diagnosis includes urothelial carcinoma, bladder cancer, urinary tract infection, kidney stones, and benign prostatic hyperplasia.  Urinalysis demonstrates [urinalysis findings, e.g., microscopic hematuria, pyuria].  Urine cytology ordered.  Imaging studies including CT urogram or cystoscopy are indicated to evaluate for bladder cancer and assess the upper urinary tract.  Preliminary diagnosis of urothelial carcinoma is suspected.  Patient was counseled on the findings and potential treatment options including surgery, chemotherapy, radiation therapy, immunotherapy, and bladder preservation strategies.  Referral to urology and oncology for further evaluation and management is recommended.  Patient education provided regarding the signs and symptoms of urothelial carcinoma, diagnostic procedures, treatment modalities, potential complications, and follow-up care.  ICD-10 code C67 will be used for malignant neoplasm of bladder, based on the presumed primary site.  Further coding will be determined upon definitive diagnosis and staging.  Follow-up scheduled in [timeframe] to review imaging results and discuss next steps in the treatment plan.