Demographics & Encounter
Patient ID159126 (PHI redacted)
Age / Gender72 / Male
Date of Service2026-04-13
ProviderNone
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerUHC
Reason1. HOSP F/U** RECS IN CHART
Diagnoses
R33.9
Urinary retention
C67.9
Malignant neoplasm of bladder, part unspecified
N47.1
Phimosis
Medications
Vitamin B1
Polyethylene Glycol
Pantoprazole Sodium
Metoprolol Tartrate
Melatonin
Ergocalciferol
Divalproex Sodium ER
Atorvastatin Calcium
Apixaban
Docusate Sodium
Aspirin
Tamsulosin HCl 0.4 MG Capsule 1 cap(s) orally once a day
Finasteride
Thiamine HCl
Eliquis(Apixaban)
REFLUX Oral
Vitamin B 12
oxyBUTYnin Chloride ER
oxyBUTYnin Chloride
Ciprofloxacin HCl
Omega 3
Multivitamin
Rosuvastatin Calcium
Midazolam
Fycompa(Perampanel)
Past Medical History
- High Blood Pressure
- High Cholesterol
- Anemia
- Gross Hematuria
- Renal disease
- Dementia
Clinical Summary (HPI)
Bladder Cancer: 72yM w/ hx of non-muscle invasive bladder cancer and urinary retention presents for hospital f/u and TOV. The patient went to Sentara, with AUR-he has a catheter in place. On Flomax. He has had a stroke in the interim-undergoing physical therapy. - - - - - - - - - - - - - - Prior hx: Since last visit, he was admitted to Inova 4/2025 with concerns for psychosis with agitation and paranoid behavior/hallucinations likely underlying vascular and EtOH induced dementia Has history of Alcohol abuse and history of Wernicke's encephalopathy - - - - - - - - - - - - - - The patient's previous work-up history is listed below: Labs (03/06/2026): RBC 3.28, HCT 32.4, MCV 98.8, Cr 0.9, CTap w/wo IV cont (03/2026): No hydronephrosis, calcified stones. Aortobiliac stent with endoleak into excluded lymen, probably type II. Type II cannot be excluded. Excluded lumen 4.9 cm. Labs (01/2026): RBC 3.6, HGB 11.8, HCT 34.4, MCV 96. Ca 8, BUN 24, Cr 1.1 CT Chest/Abd/Pelvis w/o Con (12/2025): Left lower lobe opacities with peribronchial cuffing. Advanced pulmonary emphysema. Infrarenal AAA measuring 5 cm, s/p aortoiliac endograft repair. Mild circumferential urinary bladder wall thickening. Right kidney midpole 10 mm indeterminate density likely proteinaceous cyst. (reviewed and interpreted) Labs (4/2025): Cr 1.3, 11.6 Hb, maintenance Mitomycin (01/2025, 04/2025, 08/2025)- skipped/missed other treatments due to inpatient hospitalization Cysto 10/2024: negative. Cytology/FISH negative. In
Raw Note (de-identified preview)
4/16/26, 12:45 AM Print Preview
[PATIENT_NAME] DOB: [DOB] (72 yo M) Acc No. [ACCOUNT_ID] DOS: 04/13/2026
[PATIENT_NAME]
72 Y old Male, DOB: [DOB]
Account: [ACCOUNT_ID]: [PHONE] [ADDRESS]
Home: [PHONE]
Guarantor: [GUARANTOR_NAME] Insurance: UHC
MEDICARE
PCP: [PROVIDER_NAME], PA Referring: [PROVIDER_NAME], PA
Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge
Structured Data: How did you hear about us? : Other; Patient's temperature : 0; : 07/18/2022
04/13/2026 [PROVIDER_NAME], PA
Reason for Appointment
1. HOSP F/U** RECS IN CHART
History of Present Illness
Bladder Cancer:
72yM w/ hx of non-muscle invasive bladder cancer and urinary retention presents for hospital f/u and TOV.
The patient went to Sentara, with AUR-he has a catheter in place. On Flomax.
He has had a stroke in the interim-undergoing physical therapy.
- - - - - - - - - - - - - -
Prior hx:
Since last visit, he was admitted to Inova 4/2025 with concerns for psychosis with agitation and paranoid
behavior/hallucinations likely underlying vascular and EtOH induced dementia
Has history of Alcohol abuse and history of Wernicke's encephalopathy
- - - - - - - - - - - - - -
The patient's previous work-up history is listed below:
Labs (03/06/2026): RBC 3.28, HCT 32.4, MCV 98.8, Cr 0.9,
CTap w/wo IV cont (03/2026): No hydronephrosis, calcified stones. Aortobiliac stent with endoleak into excluded lymen,
probably type II. Type II cannot be excluded. Excluded lumen 4.9 cm.
Labs (01/2026): RBC 3.6, HGB 11.8, HCT 34.4, MCV 96. Ca 8, BUN 24, Cr 1.1
CT Chest/Abd/Pelvis w/o Con (12/2025): Left lower lobe opacities with peribronchial cuffing. Advanced pulmonary
emphysema. Infrarenal AAA measuring 5 cm, s/p aortoiliac endograft repair. Mild circumferential urinary bladder wall
thickening. Right kidney midpole 10 mm indeterminate density likely proteinaceous cyst. (reviewed and interpreted)
Labs (4/2025): Cr 1.3, 11.6 Hb,
maintenance Mitomycin (01/2025, 04/2025, 08/2025)- skipped/missed other treatments due to inpatient hospitalization
Cysto 10/2024: negative. Cytology/FISH negative.
Induction mitomycin (7-8/2024)
*Cysto, TURBT, post op mitomycin (5/29/24): 3 cm papillary tumor (intravesical height 1 cm, base 3cm) along LLW.
Resected to completion with visual muscle in specimen.
PATHOLOGY: HGTa (primarily noninvasive low grade papillary urothelial carcinoma with focal high grade 5%)
Cystoscopy (3/2024): bladder tumor on the left lateral wall 3 cm, mild trabeculations, lateral lobe enlargement
Ct abd/pel (03/2024): Persistent plaque like thickening along left lateral urinary bladder wall sus for underlying neoplasm.
No pelvic lymphadenopathy. Bilatearl renal cysts . Indeterminate hypodensity in interpolar right kidney, most likely
hemorrhagic/protenaceous cyst
Cytology (03/2024) :negative for malignancy
CT A/P IV only: Partally imaged left seventh posterolateral rib fracture with ongoing callus formation likely subacute (2)
Plaque-like foci thickening of the left lateral urinary bladder wall, given h