Patient Note — 19302

progress_notes_19302_1_deid.txt

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Demographics & Encounter

Patient ID19302 (PHI redacted)
Age / Gender58 / Male
Date of Service2025-12-15
ProviderNone
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerSentara
Reason1. Blood in urine

Diagnoses

R31.0 Gross hematuria
N20.0 Renal calculi

Medications

Trospium Chloride traZODone HCl Progress Note: STELLA Y BASOAH 12/15/2025 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/12/2026 04:33 PM EDT 1/4 4/13/26, 2:03 AM Print Preview [PATIENT_NAME] DOB: [DOB] (58 yo M) Acc No. [ACCOUNT_ID] DOS: 12/15/2025 Atorvastatin Calcium Sertraline HCl Medication List reviewed and reconciled with the patient

Past Medical History

  • Enlarged Prostate
  • ED

Vitals

RR 16.0
HR 1.0
BP 1
BMI 29.12
WEIGHT 233 lbs
HEIGHT_IN 75.0

Clinical Summary (HPI)

Kidney Stone: 58yM w/ hx of kidney stones, s/p L URS LL (11/04/2025) presents today with gross hematuria. He notes that he went to ER 12/8 with recurrent LLQ/ left flank pain which improved over time. No acute findings on repeat imaging. He was discharged with Toradol. He says since the ER, he experienced episodes of gross hematuria, unsure if he's been passing stones, but also dissipated over time. ++++++++++++++++++++++++++++++ The patient's previous workup history is listed below: CT a/p: 1. No acute abnormality.2. Cholelithiasis.3. Nonobstructing left renal calculi.4. Small bowel adhesions (12/8/225) S/p Cystoscopy, Ureteral Catheter Insertion, Interpretation of Fluroscopic Images, Left Flexible Nephroscopy, Left Flexible Ureteroscopy, Laser Lithotripsy, Left 6F x 30 cm double J Ureteral Stent Insertion: Left renal stones. (11/04/2025) CT A/P (Sentara): Mild left hydronephrosis secondary to UPJ obstructing 8mm calculus. Additional left renal nonobstructing calculi measure up to 11mm. Gallstones. Partial sigmoidectomy. [10/07/2025]. Overactive Bladder: Also, w/ hx of overactive bladder. Continues Trospium 20 mg BID. BPH screening: Pt w/ hx of ED and BPH, s/p Aquablation Monotherapy (02/27/2025), ++++ Cysto: Open prostate [06/30/2025] surg path (Feb 2025): Benign PSA: 0.66 (Oct 2024) Cysto: lateral lobe enlargement, bladder trabeculation (Jan'25) Urocuff study has an obstructed appearance with a peak flow rate of 9.9 ml/s, cuff pressure of 200 cmH2O, voided volume of 125 mL

Raw Note (de-identified preview)

4/13/26, 2:03 AM Print Preview [PATIENT_NAME] DOB: [DOB] (58 yo M) Acc No. [ACCOUNT_ID] DOS: 12/15/2025 [PATIENT_NAME] 58 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [ACCOUNT_ID] [ADDRESS] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Sentara Health Plans (FNA Optima) PCP: MELANY WIEST Referring: ALOK S DESAI Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge 12/15/2025 Progress Notes: STELLA Y BASOAH Reason for Appointment 1. Blood in urine History of Present Illness Kidney Stone: 58yM w/ hx of kidney stones, s/p L URS LL (11/04/2025) presents today with gross hematuria. He notes that he went to ER 12/8 with recurrent LLQ/ left flank pain which improved over time. No acute findings on repeat imaging. He was discharged with Toradol. He says since the ER, he experienced episodes of gross hematuria, unsure if he's been passing stones, but also dissipated over time. ++++++++++++++++++++++++++++++ The patient's previous workup history is listed below: CT a/p: 1. No acute abnormality.2. Cholelithiasis.3. Nonobstructing left renal calculi.4. Small bowel adhesions (12/8/225) S/p Cystoscopy, Ureteral Catheter Insertion, Interpretation of Fluroscopic Images, Left Flexible Nephroscopy, Left Flexible Ureteroscopy, Laser Lithotripsy, Left 6F x 30 cm double J Ureteral Stent Insertion: Left renal stones. (11/04/2025) CT A/P (Sentara): Mild left hydronephrosis secondary to UPJ obstructing 8mm calculus. Additional left renal nonobstructing calculi measure up to 11mm. Gallstones. Partial sigmoidectomy. [10/07/2025]. Overactive Bladder: Also, w/ hx of overactive bladder. Continues Trospium 20 mg BID. BPH screening: Pt w/ hx of ED and BPH, s/p Aquablation Monotherapy (02/27/2025), ++++ Cysto: Open prostate [06/30/2025] surg path (Feb 2025): Benign PSA: 0.66 (Oct 2024) Cysto: lateral lobe enlargement, bladder trabeculation (Jan'25) Urocuff study has an obstructed appearance with a peak flow rate of 9.9 ml/s, cuff pressure of 200 cmH2O, voided volume of 125 mL, and PVR: 30 mL. (Oct 2024). Current Medications Taking Trospium Chloride 20 MG Tablet 1 tablet Orally Twice a day traZODone HCl 50 MG Tablet TAKE ONE-HALF TO ONE TABLET BY MOUTH NIGHTLY AS NEEDED Oral Progress Note: STELLA Y BASOAH 12/15/2025 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/12/2026 04:33 PM EDT 1/4 4/13/26, 2:03 AM Print Preview [PATIENT_NAME] DOB: [DOB] (58 yo M) Acc No. [ACCOUNT_ID] DOS: 12/15/2025 Atorvastatin Calcium 20 MG Tablet Oral Sertraline HCl 50 MG Tablet TAKE ONE TABLET BY MOUTH EVERY DAY Oral Medication List reviewed and reconciled with the patient Past Medical History Enlarged Prostate. ED. Surgical History colon resection Aquablation 02/2025 CYSTO LEFT URS LL with stent placement 11/04/25 Family History Father: deceased Mother: deceased, colon cancer, breast cancer Social History Smoking: no Recreational drug use: no. Exercise: no. Caffeine: yes. Sexually active: no. Occupation: no. Toba