Patient Note — 249188
progress_notes_249188_1_deid.txt
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
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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