Patient Note — 118074

progress_notes_118074_1_deid.txt

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Demographics & Encounter

Patient ID118074 (PHI redacted)

Age / Gender86 / Male

Date of Service2025-11-19

ProviderNone

FacilityPOTOMAC UROLOGY CENTER - Woodbridge

PayerMedicare VA

Reason1. CYSTO LOCAL

Diagnoses

C67.9 Malignant neoplasm of bladder, unspecified

C61 Malignant neoplasm of prostate

I10 Asymptomatic hypertension

N39.0 Acute UTI

R60.0 Lower extremity edema

R03.0 Elevated blood pressure reading

N48.1 Balanitis

Medications

Ambien Aspirin IRON, 2500 G Multivitamin Simvastatin Tamsulosin HCl Zolpidem Tartrate Furosemide Carvedilol Orgovyx(Relugolix) Nystatin 100000 UNIT/GM Cream 1 application Externally 3 times a day Sulfamethoxazole-Trimethoprim 800-160 MG Tablet 1 tab(s) orally twice a day Pyridium(Phenazopyridine HCl) Medication List reviewed and reconciled with the patient

Past Medical History

Heart attack
Hypertension
a Fib

Vitals

BMI 26.9

WEIGHT 182.2 lbs

HEIGHT_IN 69.0

Clinical Summary (HPI)

Bladder Cancer: 86 yM with bladder cancer presents for cystoscopy. BCG ending on August 6 2024. - - - - - - - - - - - - - - - - - - - - - - TURBT: (1) High grade papillary urothelial carcinoma, noninvasive (2) Focal muscularis propria present, no evidence of tumor involvement (Mar 2024) CT chest (3/2020): numerous pulmonary nodules, mediastinal and hilar adenopathy NMBone scan (Nov 2019): no evidence of bony metastasis Path: high-grade intraepithelial neoplasia (Jan 2020); GL 4+3=7; PSA 5.9 (2010) cytology: Atypia, FISH: Positive (Oct 2022), Uninterpretable; need to repeat (Sept 2022), malignant cells present, fish: positive (May 2022), malignant cells present, favor urothelial carcinoma, Positive FISH (Jul 2021); atypia, pos FISH (Sep 2020) malignant cells present, pos FISH (Jul 2020) cysto: no mass or lesion (Jul 2021); small area of erythema at the bladder dome (Mar 2021) Bladder bx: (A) Dome of bladder: Carcinoma in situ, Muscularis propria present. (B) R Side of Wall: (1) Benign urothelial mucosa, denuded, Muscularis propria present (Oct 2021) - (Mar 2021): Benign urothelium with erosion and granulation tissue TURBT: showed a high grade intraepithelial neoplasia; No muscularis propria present; There is an intact fragment of bladder tissue showing at least carcinoma-in-situ. There are also minute, detached fragment of high grade epithelium in association with necrosis. An invasive process cannot be excluded. (Jan 2022). Prostate Cancer (advanced): also with a hx of prosta

Raw Note (de-identified preview)

4/23/26, 6:36 AM Print Preview [PATIENT_NAME] DOB: [DOB] (86 yo M) Acc No. [ACCOUNT_ID] DOS: 11/19/2025 [PATIENT_NAME] 86 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [PHONE] [ADDRESS] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Medicare VA (Palmetto) PCP: DR ROBERT J GIBSON Referring: DR ROBERT J GIBSON Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge Structured Data: How did you hear about us? : Other; Patient's temperature : 97.1; : 10/18/2022 11/19/2025 CYSTOSCOPY: Pratik S. Desai, MD Reason for Appointment 1. CYSTO LOCAL History of Present Illness Bladder Cancer: 86 yM with bladder cancer presents for cystoscopy. BCG ending on August 6 2024. - - - - - - - - - - - - - - - - - - - - - - TURBT: (1) High grade papillary urothelial carcinoma, noninvasive (2) Focal muscularis propria present, no evidence of tumor involvement (Mar 2024) CT chest (3/2020): numerous pulmonary nodules, mediastinal and hilar adenopathy NMBone scan (Nov 2019): no evidence of bony metastasis Path: high-grade intraepithelial neoplasia (Jan 2020); GL 4+3=7; PSA 5.9 (2010) cytology: Atypia, FISH: Positive (Oct 2022), Uninterpretable; need to repeat (Sept 2022), malignant cells present, fish: positive (May 2022), malignant cells present, favor urothelial carcinoma, Positive FISH (Jul 2021); atypia, pos FISH (Sep 2020) malignant cells present, pos FISH (Jul 2020) cysto: no mass or lesion (Jul 2021); small area of erythema at the bladder dome (Mar 2021) Bladder bx: (A) Dome of bladder: Carcinoma in situ, Muscularis propria present. (B) R Side of Wall: (1) Benign urothelial mucosa, denuded, Muscularis propria present (Oct 2021) - (Mar 2021): Benign urothelium with erosion and granulation tissue TURBT: showed a high grade intraepithelial neoplasia; No muscularis propria present; There is an intact fragment of bladder tissue showing at least carcinoma-in-situ. There are also minute, detached fragment of high grade epithelium in association with necrosis. An invasive process cannot be excluded. (Jan 2022). Prostate Cancer (advanced): also with a hx of prostate cancer (He had hx of seeds in 2015) here for PSA/testo review He reports surgery went well. Had a bleeding and dysuria for three days but was cleared he denies any urinary symptoms today - - - - - - - - - - - - - - - - - - - - - PSA: 0.05 (March 2025), 0.03 (Jun 2023), 0.01 (Mar 2023), 0.04 (Sep 2022), 0.15 (Apr 2021), 0.29 (Jul 2020), 8.0 (Dec 2019), 5.37 (Jun 2019), 4.95 (Dec 2018), 2.79 (Jun 2018), 0.82 (Jun 2017), 0.19 (Jun 2016) Testo: 0 (March 2025), 0 (Jun 2023), 13 (Mar 2023), 0 (Sep 2022) Eligard: #1 (Feb 2020) #2 (Sep 2020) #3 (Apr 2021) #4 (Nov 2021) #5 (Jun 21 2021) # 6 (06/21/2022) #7 (4/11/2023 - 3M dose) #8 (07/11/2023) Camcevi: #1 (9/27/2022) # 01/23/2024. Progress Note: [PROVIDER_NAME], MD 11/19/2025 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/23/2026 09:36 AM EDT 1/4 4/23/26, 6:36 AM Print Preview [PATIENT_N