Subsequent Urology Evaluation (Increased PSA) Template

CHIEF COMPLAINT:  
Patient presents to the office today to discuss:  
1. Elevated PSA  
2. Frequent urination  
3. Lower back pain  
PAST UROLOGICAL HISTORY:  
Mr. John Smith, a 65-year-old retired engineer who enjoys gardening, has been under my care for the past two years. His initial consultation was due to elevated PSA levels, which were 5.2 ng/mL on 01/15/2022. A subsequent MRI on 03/10/2022 showed no significant lesions. He underwent a prostate biopsy on 04/20/2022, which revealed benign prostatic hyperplasia. Dr. Emily Carter, his primary care physician, has been involved in his care.  
PSA HISTORY:  
- 01/15/2022: 5.2 ng/mL  
- 07/20/2023: 6.0 ng/mL  
- 10/25/2024: 6.5 ng/mL  
- PSA Density calculated by dividing the latest PSA by last known prostate size: 0.15 ng/mL/cm³  
PROSTATE BIOPSY HISTORY:  
- 04/20/2022: Benign prostatic hyperplasia  
HPI TODAY 11/01/2024:  
- Mr. Smith reports increased frequency of urination, particularly at night, which has worsened over the past month. He denies any hematuria or dysuria.  
- Recent ultrasound on 10/20/2024 at City Hospital showed an enlarged prostate with no suspicious lesions. I personally reviewed and independently interpreted the scan and concur with findings.  
- AUA Symptom score: 18  
- PVR: 50 mL  
PMH, PSH, MEDS, ALLERGIES, SH, and FH:  
- No new updates.  
PHYSICAL EXAMINATION:  
Constitutional: Well-nourished, in no acute distress. Alert and oriented.  
Psychiatric: Calm and cooperative. Appropriate mood and affect.  
GU exam: Prostate enlarged, non-tender.  
ASSESSMENT AND PLAN:  
Mr. Smith is a 65-year-old man with a history of elevated PSA and benign prostatic hyperplasia.  
1. Elevated PSA (R97.2)  
- Assessment: PSA levels have slightly increased, but remain stable.  
- Plan: Continue monitoring PSA levels every six months.  
- Counseling: Discussed the natural history of PSA fluctuations and the importance of regular monitoring.  
2. Benign Prostatic Hyperplasia (N40.1)  
- Assessment: Symptoms of BPH are worsening.  
- Plan: Initiate tamsulosin 0.4 mg daily to alleviate urinary symptoms.  
- Counseling: Explained the mechanism of tamsulosin and potential side effects.  
3. Lower back pain (M54.5)  
- Assessment: Likely musculoskeletal in origin.  
- Plan: Recommend physical therapy and over-the-counter analgesics as needed.  
ORDERS:  
- Tamsulosin 0.4 mg daily  
FOLLOW UP:  
- Follow-up in six months with repeat PSA test.  
SHORT SUMMARY:  
Mr. Smith, a 65-year-old man, presents with elevated PSA and worsening BPH symptoms. Initiated tamsulosin for symptom relief and scheduled follow-up in six months.