Patient Note — 249188

progress_notes_249188_1_deid.txt

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Demographics & Encounter

Patient ID249188 (PHI redacted)
Age / Gender67 / Male
Date of Service2026-03-02
ProviderNone
FacilityNone
PayerNone
ReasonNone

Diagnoses

No diagnoses extracted

Raw Note (de-identified preview)

4/8/26, 3:54 PM Print Preview [PATIENT_NAME] DOB: [DOB] (67 yo M) Acc No. [ACCOUNT_ID] DOS: 03/02/2026 Annual Visit Patient: [PATIENT_NAME] Provider: [PROVIDER_NAME] MD Account: [ACCOUNT_ID] DOB: [DOB] Age: 67 Y Sex: Male Date: 03/02/2026 Phone: [PHONE] Address: [ADDRESS] Pcp: [PROVIDER_NAME] Subjective: Chief Complaints: 1. 1 YEAR F/U. HPI: General Urology: 67yM, wityh hx of BPH, comes for [ADDRESS] Min and a written report will be sent to the provider. BPH S/p UroLift, satisifed. on Finasteride. Noct x2. PSA: 2.28 (04/16/2025) Gross Hematuria Exp GH now. Had microscopic Hmeaturia in the past. - - - - - - - - - - - - - - - - Treatment: Previous Work-Up Includes: Imaging Studies: Lab Results:. ROS: 11 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the patient cdw. Medical History: Hyperlipidemia, Hypertension, Diabetes mellitus, BPH. Surgical History: Greenlight Laser Treatment of BPH , cholecystectomy . Family History: Father: deceased. Mother: deceased. Screening: Social History: Smoking: no . Recreational drug use: no. Caffeine: yes, frequency: one cup a day. Sexually active: yes. Occupation: yes. 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? 2 to 4 times a month (2 points) How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 drinks (0 Provider: [PROVIDER_NAME] MD Date: 03/02/2026 Generated for Printing/Faxing/eTransmitting on: 04/08/2026 06:24 AM EDT 1/5 4/8/26, 3:54 PM Print Preview [PATIENT_NAME] DOB: [DOB] (67 yo M) Acc No. [ACCOUNT_ID] DOS: 03/02/2026 point) How often did you have six or more drinks on one occasion in the past year? Never (0 point) Points 2 Interpretation Negative Medications: Taking Glimepiride , Taking Rosuvastatin Calcium 40 MG Tablet TAKE 1 TABLET BY MOUTH EVERY DAY Oral , Taking metFORMIN HCl 1000 MG Tablet Oral , Taking Finasteride 5 MG Tablet TAKE 1 ACTUATION AS DIRECTED DAILY Oral , Taking amLODIPine Besylate 5 MG Tablet TAKE 1 TABLET BY MOUTH EVERY DAY Oral , Taking Omeprazole 20 MG Capsule Delayed Release Oral , Taking Losartan Potassium 100 MG Tablet Oral , Taking Pioglitazone HCl , Not-Taking Ezetimibe 10 MG Tablet Oral , Not-Taking Finasteride 5 MG Tablet 1 tab(s) orally once a day , Medication List reviewed and reconciled with the patient Allergies: Blue Crab (Diagnostic). Objective: Vitals: RR: 16, HR: 72, BP: 110/66 mm Hg, Ht: 65, Wt: 155 lbs, BMI: 25.79 Index. Examination: Assessment: Assessment: 1. Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1 (Primary) 2. Elevated PSA - R97.20 3. Gross hematuria - R31.0 Plan: Treatment: 1. Benign prostatic hyperplasia with lower urinary tract symptoms Refill Finasteride Tablet, 5 MG, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 . Notes: Patient is s/p UroLift, satisifed. He is currently on Finasteride. He elects to continue finaster