Urology - New Patient Template

CHIEF COMPLAINT:  
Patient presents to the office today to discuss:  
1. Frequent urination  
2. Blood in urine  
3. Lower abdominal pain  
PAST UROLOGICAL HISTORY  
- Diagnosed with benign prostatic hyperplasia (BPH) in 2020, treated with medication.  
- Underwent cystoscopy in March 2023, findings were normal.  
HPI TODAY 11/01/2024:  
- Increased frequency of urination, especially at night, noted over the past month.  
- Hematuria observed intermittently for the last two weeks.  
- Lower abdominal pain persisting despite medication.  
- Ultrasound of the kidneys and bladder performed on 10/25/2024 at City Hospital. I personally reviewed and independently interpreted the scan and concur with findings of mild bladder wall thickening.  
- Urinalysis shows presence of red blood cells.  
- Reports nocturia 3 times per night, urgency, and decreased stream.  
- AUA Symptom score: 18  
PMH, PSH, MEDS, ALLERGIES, SH, and FH:  
- PMH: Hypertension, managed with lisinopril.  
- MEDS: Tamsulosin, lisinopril.  
- ALLERGIES: No known drug allergies.  
- SH: Non-smoker, occasional alcohol use.  
- FH: Father had prostate cancer.  
PHYSICAL EXAMINATION:  
Constitutional: Alert, no acute distress.  
Psychiatric: Mood and affect normal, cooperative behavior.  
GU exam: Mild tenderness in lower abdomen, prostate slightly enlarged on digital rectal exam.  
Cystoscopy:  
Performed today, findings include mild bladder wall thickening, no tumors observed.  
ASSESSMENT AND PLAN:  
1. Benign prostatic hyperplasia (BPH) (ICD-10: N40.1)  
- Assessment: Symptoms suggest progression of BPH.  
- Plan: Increase tamsulosin dosage, follow-up in 3 months. Discussed potential surgical options if symptoms persist.  
- Counseling: Explained BPH progression and management options.  
2. Hematuria (ICD-10: R31.9)  
- Assessment: Likely related to BPH, but further investigation needed.  
- Plan: Schedule CT urogram to rule out other causes. Follow-up in 2 weeks.  
- Counseling: Discussed possible causes of hematuria and need for further testing.  
3. Lower abdominal pain (ICD-10: R10.30)  
- Assessment: Likely related to urinary issues.  
- Plan: Monitor symptoms, consider pain management options if necessary.  
- Counseling: Advised on pain management strategies and when to seek further care.  
SUMMARY  
Today's visit focused on the patient's increased urinary symptoms, hematuria, and abdominal pain. We have adjusted medication for BPH and planned further imaging to investigate hematuria. Follow-up appointments are scheduled to monitor progress and reassess treatment options.