Patient Note — 256901
progress_notes_256901_1_deid.txt
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 patientPast 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,