Patient Note — 133742

4/16/26, 12:44 AM Print Preview [PATIENT_NAME] DOB: [DOB] (70 yo M) Acc No. [ACCOUNT_ID] DOS: 10/29/2024 [PATIENT_NAME] 70 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [PHONE] [ADDRESS] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Medicare VA (Palmetto) PCP: [PROVIDER_NAME], MD Referring: [PROVIDER_NAME], MD Appointment Facility: POTOMAC UROLOGY CENTER - Manassas Structured Data: How did you hear about us? : Other; Patient's temperature : 95; : 08/24/2022 10/29/2024 CYSTOSCOPY: ASEEM MALHOTRA, MD Reason for Appointment 1. CYSTO LOCAL History of Present Illness Bladder cancer: 70 yM with history of bladder cancer. He presents for cystoscopy local Abnormal area was visualized (May'23) but resolved itself (Jun'23) Pt BP elevated today, patient had back surgery last week - - - - - - - - The patient's previous work-up history is listed below: Pathology: High grade papillary non-invasive bladder UC Treatment: 2 courses of BCG x 6 weeks (at Fort Belvoir); TURBT (May 2014) Cystoscopy: (May 2022) No recurrence. Lateral lobe enlargement, Prostate Vol: 50grams (May 2021) No recurrence. Mild/mod lateral lobe enlargement, mild trabeculation (Apr 2020) Lateral lobe enlargement, intravesical protrusion, mild trabeculation, small R Lat Wall diverticulum CT: No urinary bladder mass identified, enlarged prostate gland with slight indentation in the base of urinary bladder (Apr 2020). Current Medications Taking Brilinta(Ticagrelor) 60 MG Tablet 1 tab(s) orally 2 times a day hydroCHLOROthiazide Lisinopril Cephalexin 500 MG Capsule TAKE ONE CAPSULE BY MOUTH TWICE A DAY Oral Not-Taking Simvastatin Tamsulosin HCl 0.4 MG Capsule 1 cap(s) orally once a day HYDROcodone-Acetaminophen 5-325 MG Tablet Oral Medication List reviewed and reconciled with the patient Past Medical History Bladder Cancer. Arthritis. Hypertension. Hyperlipidemia. Vascular Disease. Progress Note: [PROVIDER_NAME], MD 10/29/2024 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/16/2026 03:44 AM EDT 1/4 4/16/26, 12:44 AM Print Preview [PATIENT_NAME] DOB: [DOB] (70 yo M) Acc No. [ACCOUNT_ID] DOS: 10/29/2024 Surgical History back surgery neck CYSTOSCOPY ureteral stent placement circumcision Family History Father: deceased, diagnosed with Malignant neoplasm of prostate, Malignant neoplasm of bladder, unspecified Mother: deceased Social History Smoking: yes Are you a: current smoker How often do you smoke cigarettes? Every day How many cigarettes a day do you smoke? 6 - 10 How soon after you wake up do you smoke your first cigarette? 31 - 60 min Are you interested in quitting? Not ready to quit Recreational drug use: no. Exercise: yes. Caffeine: yes, frequency:. Alcohol: socially Did you have a drink containing Alcohol in the past year? Yes Points 0 Interpretation Negative Sexually active: no. Occupation: no, Retired. Allergies Plavix Hospitalization/Major Diagnostic Procedure Denies Past Hospitalization Review of Systems 1