Patient Note — 256901

progress_notes_256901_1_deid.txt

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Demographics & Encounter

Patient ID256901 (PHI redacted)
Age / Gender64 / Male
Date of Service2026-04-07
ProviderNone
FacilityPOTOMAC UROLOGY CENTER - Manassas
PayerAetna Foreign Service
Reason1. REV UROCUFF

Diagnoses

N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
N52.9 Erectile dysfunction, unspecified erectile dysfunction type
Z12.5 Screening PSA (prostate specific antigen)

Medications

buPROPion HCl ER (XL) lamoTRIgine traZODone HCl OLANZapine Gabapentin Tamsulosin HCl 0.4 MG Capsule 1 cap(s) orally once a day Tadalafil Medication List reviewed and reconciled with the patient

Past Medical History

  • Medical History Verified

Vitals

RR 16.0
BMI 3.43
WEIGHT 180 lbs
HEIGHT_IN 5.0

Clinical Summary (HPI)

BPH screening: 64yM, with BPH symptoms, presents today for Urocuff review. ------------------- Urinary complaints: frequency, urgency, incomplete emptying, weak stream, nocturia x2 He was previously managing urinary and ED symptoms with Tadalafil 5 mg qd. - - - - - - - - - - - - - - - - - - Urocuff (3/31/26) VV 126, Qmax 6.9, Pcuff 108, PVR 49, obstructed IPSS: 33 (July'25) PSA: 1.01 (July'25) s/p varicocelectomy. Erectile Dysfunction screening: Also with hx of ED, well-managed with Tadalafil 5 mg qd.

Raw Note (de-identified preview)

4/23/26, 6:50 AM Print Preview [PATIENT_NAME] DOB: [DOB] (64 yo M) Acc No. [ACCOUNT_ID] DOS: 04/07/2026 [PATIENT_NAME] 64 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [PHONE] [ADDRESS] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Aetna Foreign Service Benefits Plan PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME] Appointment Facility: POTOMAC UROLOGY CENTER - Manassas 04/07/2026 Progress Notes: STELLA Y BASOAH Reason for Appointment 1. REV UROCUFF History of Present Illness BPH screening: 64yM, with BPH symptoms, presents today for Urocuff review. ------------------- Urinary complaints: frequency, urgency, incomplete emptying, weak stream, nocturia x2 He was previously managing urinary and ED symptoms with Tadalafil 5 mg qd. - - - - - - - - - - - - - - - - - - Urocuff (3/31/26) VV 126, Qmax 6.9, Pcuff 108, PVR 49, obstructed IPSS: 33 (July'25) PSA: 1.01 (July'25) s/p varicocelectomy. Erectile Dysfunction screening: Also with hx of ED, well-managed with Tadalafil 5 mg qd. Current Medications Taking buPROPion HCl ER (XL) 300 MG Tablet Extended Release 24 Hour Oral lamoTRIgine 100 MG Tablet Oral traZODone HCl 100 MG Tablet Oral OLANZapine 5 MG Tablet Oral Gabapentin 300 MG Capsule Oral Tamsulosin HCl 0.4 MG Capsule 1 cap(s) orally once a day Tadalafil 5 MG Tablet 1 tab(s) orally once a day Medication List reviewed and reconciled with the patient Past Medical History Medical History Verified. Surgical History BACK SX Progress Note: STELLA Y BASOAH 04/07/2026 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/23/2026 09:50 AM EDT 1/3 4/23/26, 6:50 AM Print Preview [PATIENT_NAME] DOB: [DOB] (64 yo M) Acc No. [ACCOUNT_ID] DOS: 04/07/2026 Family History Father: deceased Mother: deceased father- liver cancer. Social History Smoking: no Recreational drug use: no. Exercise: no. Caffeine: yes, frequency: 1 cup of coffee per day. Sexually active: yes. Screening Allergies N.K.D.A. Hospitalization/Major Diagnostic Procedure No Hospitalization History. Review of Systems 11 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the patient. jc. Vital Signs RR: 16, HR: Not Taken - Collection Device Broken, BP: Not Taken - Collection Device Broken, Ht: 5'11 ft, Wt: 180 lbs, BMI: 3.43 Index. Assessments 1.Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1 (Primary) 2.Erectile dysfunction, unspecified erectile dysfunction type - N52.9 3.Screening PSA (prostate specific antigen) - Z12.5 Treatment 1.Benign prostatic hyperplasia with lower urinary tract symptoms Continue Tamsulosin HCl Capsule, 0.4 MG, 1 cap(s), orally, once a day, 90 days, 90 Capsule, Refills 3 Clinical Notes: He admits to improved flow with Tamsulosin. Elects to continue. The patient is taking Tamsulosin 0.4 mg qd for symptom relief. He says initially there was improvement in LUTS, but not so much anymore. We reviewed Urocuff results: VV 126, Qmax 6.9,