Patient Note — 162179
progress_notes_162179_1_deid.txt
Demographics & Encounter
Patient ID162179 (PHI redacted)
Age / Gender— / —
Date of Service2026-04-03
Provider[PROVIDER_NAME]
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerCareFirst BCBS
Reason1. 1 MONTH f/ u
Diagnoses
N32.81
OAB (overactive bladder)
R35.0
Urinary frequency
Z12.5
Prostate cancer screening
E29.1
Testicular hypofunction
R10.30
Lower abdominal pain
R35.1
Nocturia
Medications
Aspirin metFORMIN HCl Pregabalin Simvastatin Trospium Chloride Percocet Cephalexin Pyridium(Phenazopyridine HCl) TadalafilPast Medical History
- High cholesterol
- Diabetes
- Erectile Dysfunction
- Low Testosterone
Clinical Summary (HPI)
Low Testosterone: [AGE]yM w/ hx of low testosterone and OAB presents today for Uroflow PVR -------------- Treatment: Aveed (Current) Testo: 272 (Jan 2023) PSA(Feb 2026): 1.4 CT (Feb 2026): Thickened bladder wall can be due to underdistention. Correlate withurinalysis to exclude cystitis. (Independently reviewed the actual images/tracings and came to my own conclusions).
Raw Note (de-identified preview)
4/15/26, 1:53 PM Print Preview
[PATIENT_NAME] DOB: [DOB] ([AGE] yo M) Acc No. [ACCOUNT_ID] DOS: 04/03/2026
[PATIENT_NAME]
[AGE] Y old Male, DOB: [DOB]
Account: [ACCOUNT_ID]: [PHONE] [ADDRESS]
Home: [PHONE]
Guarantor: [GUARANTOR_NAME] Insurance: CareFirst BCBS
PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME]
Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge
Structured Data: How did you hear about us? : Other; Patient's temperature : 96.9; : 11/17/2022
04/03/2026 Progress Notes: [PROVIDER_NAME], MD
Reason for Appointment
1. 1 MONTH f/ u
History of Present Illness
Low Testosterone:
[AGE]yM w/ hx of low testosterone and OAB presents today for Uroflow PVR
--------------
Treatment: Aveed (Current)
Testo: 272 (Jan 2023)
PSA(Feb 2026): 1.4
CT (Feb 2026): Thickened bladder wall can be due to underdistention. Correlate withurinalysis to exclude cystitis.
(Independently reviewed the actual images/tracings and came to my own conclusions).
Current Medications
Taking
Aspirin 81 MG Tablet Chewable 1 tablet Orally Once a day
metFORMIN HCl
Pregabalin 100 MG Capsule 1 capsule Orally Once a day
Simvastatin 40 MG Tablet 1 tablet in the evening Orally Once a day
Trospium Chloride 20 MG Tablet 1 tablet Orally Twice a day
Not-Taking
Percocet
Cephalexin 500 MG Capsule Oral
Pyridium(Phenazopyridine HCl) 200 MG Tablet 1 tab(s) orally 3 times a day (after meals)
Tadalafil 20 MG Tablet 1 tab(s) orally prn sexual activity
Past Medical History
High cholesterol.
Diabetes.
Erectile Dysfunction.
Low Testosterone.
Surgical History
back surgery
neck surgery
Progress Note: [PROVIDER_NAME], MD 04/03/2026
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
Generated for Printing/Faxing/eTransmitting on: 04/15/2026 04:52 PM EDT
1/3
4/15/26, 1:53 PM Print Preview
[PATIENT_NAME] DOB: [DOB] ([AGE] yo M) Acc No. [ACCOUNT_ID] DOS: 04/03/2026
L ACL
Family History
Father: deceased
Mother: alive
Social History
Recreational drug use: no.
Exercise: yes.
Caffeine: yes.
Sexually active: yes.
Tobacco Control (Standard)
Tobacco use: Current smoker
AUDIT-C (Standard)
Did you have a drink containing alcohol in the past year? Yes
How often did you have a drink containing alcohol in the past year? Declined to specify (0 point)
How many drinks did you have on a typical day when you were drinking in the past year? Declined to specify (0 point)
How often did you have six or more drinks on one occasion in the past year? Declined to specify (0 point)
Points 0
Interpretation Negative
Screening
Allergies
Phenylephrine-guaiFENesin
Hospitalization/Major Diagnostic Procedure
No Hospitalization History.
Review of Systems
11 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the
patient,adg.
Vital Signs
Assessments
1.OAB (overactive bladder) - N32.81 (Primary)
2.Urinary frequency - R35.0
3.Prostate cancer screening - Z12.5
4.Testicular hypofunction - E29.1
5.Lower abdominal pain - R10.30
6.Nocturia - R35.1
Treatment
1.OAB (overactiv