Patient Note — 237879

4/21/26, 1:33 AM Print Preview [PATIENT_NAME] DOB: [DOB] (59 yo M) Acc No. [ACCOUNT_ID] DOS: 04/06/2026 [PATIENT_NAME] 59 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [ADDRESS] SE, VIENNA, VA-[ZIP] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Tricare East PGBA PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME] Appointment Facility: POTOMAC UROLOGY CENTER - Alexandria Structured Data: How did you hear about us? : Primary Care Physician; Patient's temperature : 0 04/06/2026 Progress Notes: [PROVIDER_NAME], MD Reason for Appointment 1. 3 MONTH F/U History of Present Illness Elevated PSA/Screening: Prostate biopsy Hx Previous biopsy? Yes Current Medications Taking Simvastatin 20 MG Tablet Oral buPROPion HCl ER (XL) 150 MG Tablet Extended Release 24 Hour Oral Sulfamethoxazole-Trimethoprim 800-160 MG Tablet 1 tab(s) orally every 12 hours Medication List reviewed and reconciled with the patient Past Medical History Depression. Esophageal reflux. High Cholesterol. Surgical History Fusion Bx 07/2024 SEPTOPLASTY Endoscopy Family History Father: alive 81 yrs Mother: alive 77 yrs Social History Smoking: no Recreational drug use: no. Exercise: yes. Caffeine: yes, frequency:. Alcohol: socially Type: , Frequency: ,Years: , Determination:. Sexually active: yes. Occupation: yes, CEO Self Employed. Tobacco Control (Standard) Progress Note: [PROVIDER_NAME], MD 04/06/2026 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/21/2026 04:33 AM EDT 1/4 4/21/26, 1:33 AM Print Preview [PATIENT_NAME] DOB: [DOB] (59 yo M) Acc No. [ACCOUNT_ID] DOS: 04/06/2026 Tobacco use: Nonsmoker AUDIT-C (Standard) Did you have a drink containing alcohol in the past year? No Points 0 Interpretation Negative Screening Allergies N.K.D.A. Hospitalization/Major Diagnostic Procedure Denies Past Hospitalization Review of Systems 11 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the patient...ee. Vital Signs RR: 16, HR: 70, BP: 125/95 mm Hg, Ht: 71, Wt: 230 lbs, BMI: 32.07 Index. Assessments 1.Elevated PSA - R97.20 (Primary) 2.Elevated prostate specific antigen (PSA) - R97.20 3.Family history of prostate cancer - Z80.42 4.Prostatic cyst - N42.83 Treatment 1.Elevated PSA Notes: His recent PSA was 5.3 in Ma'24, which is stable from 5.3 in Mar'24. had 2 neg bx from 2017-2019 (with findings of atypia) prostate MRI (Jun'24): one intermediate area noted in right apical peripheral zone b/w 7 and 8 o' clock; PI-RADS 3; 20 cc prostate PSA 18.5 on 7/2024 Path(7/24): Benign in 12/12 cores with no evidence of malignancy; reassured but warned against missed cancer; advised to repeat PSA periodically with a possibility of repeat biopsy in case PSA jumps up UA/UC(10/24): negative PSA(8/24): 26.8 PSA(10/24): 31.4 PSA(11/24): 11.6 Cyst noted on U/S consistent with utricular cyst, not abscess(11/24) TRUS(11/24): 49 cc prostate, midline cyst at base, consistent with utricular cyst