Patient Note — 238554

progress_notes_238554_1_deid.txt

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Demographics & Encounter

Patient ID238554 (PHI redacted)
Age / Gender75 / Female
Date of Service2025-07-23
ProviderNone
FacilityNone
PayerNone
ReasonNone

Diagnoses

No diagnoses extracted

Raw Note (de-identified preview)

4/15/26, 1:55 PM Print Preview [PATIENT_NAME] DOB: [DOB] (75 yo F) Acc No. [ACCOUNT_ID] DOS: 07/23/2025 Progress Notes Patient: [PATIENT_NAME] Provider: [PROVIDER_NAME], MD Account: [ACCOUNT_ID] DOB: [DOB] Age: 75 Y Sex: Female Date: 07/23/2025 Phone: [PHONE] Address: [ADDRESS] Pcp: [PROVIDER_NAME] Subjective: Chief Complaints: 1. Fu. HPI: General Urology: 75-year-old female with history of Papillary urothelial carcinoma, low-grade, noninvasive (pTa) s/p TURBT on 6/26/24 presents for followup. Low risk BCa 06/2024 CTU 18mm lower left lateral wall bladder mass 06/2024 TURBT LG pTa 01/2025 cysto neg 04/2025 cysto neg OAB Denies any bothersome ux sx. Noct x1. Denies any UTI or dysuria. Patient reports 2 episodes of gross hematuria, 1 without the presence of infection and the 2nd with. She then underwent ultrasound which indicates a lesion in the bladder. - - - - - - - - - - - - - - The patient's previous work-up history is listed below: Cytology (Sept'24) Atypia. S/p cysto (04/10/'25). Cysto (Sept'24) Small tumor on left posterior bladder wall. Lesion fulgurated Papillary urothelial carcinoma, low-grade, noninvasive (pTa) No muscularis propria present for evaluation. Renal/bladder ultrasound on 5/30/2024 shows solid mass in the left lateral bladder measuring up to 1.[ADDRESS] confirms bladder mass suspicious for cancer. ROS: 12 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the patient ... ML. Medical History: High Blood Pressure, High Cholesterol, Thyroid disease, Glaucoma. Surgical History: Total HYSTERECTOMY , TURPT . Hospitalization/Major Diagnostic Procedure: Denies Past Hospitalization. Family History: Father: deceased. Mother: deceased. Social History: Recreational drug use: no. Provider: [PROVIDER_NAME], MD Date: 07/23/2025 Generated for Printing/Faxing/eTransmitting on: 04/15/2026 04:54 PM EDT 1/3 4/15/26, 1:55 PM Print Preview [PATIENT_NAME] DOB: [DOB] (75 yo F) Acc No. [ACCOUNT_ID] DOS: 07/23/2025 Exercise: yes. Caffeine: yes, frequency:. Sexually active: no. Tobacco Control (Standard) Tobacco use: Nonsmoker AUDIT-C (Standard) Did you have a drink containing alcohol in the past year? Yes How often did you have six or more drinks on one occasion 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 a drink containing alcohol in the past year? Declined to specify (0 point) Points 0 Interpretation Negative Medications: Taking Simvastatin 40 MG Tablet Oral , Taking hydroCHLOROthiazide 25 MG Tablet Oral , Taking Levothyroxine Sodium 50 MCG Tablet Oral , Taking amLODIPine Besylate 5 MG Tablet Oral , Taking Carvedilol 3.125 MG Tablet Oral , Taking Zioptan(Tafluprost (PF)) 0.0015 % Solution 1 drop into affected eye in the evening Ophthalmic Once a day , Taking Oat Bran 500 MG Tablet Chewable as directed Orally , Taking Multivitamin(Multiple Vitamin) - Tablet