Patient Note — 266334
progress_notes_266334_1_deid.txt
Demographics & Encounter
Patient ID266334 (PHI redacted)
Age / Gender45 / Female
Date of Service2026-03-17
Provider[PROVIDER_NAME]
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerAnthem BCBS FEP
Reason1. Microscopic Hematuria
Diagnoses
R31.29
Microscopic hematuria
N40.1
Benign prostatic hyperplasia with lower urinary tract symptoms
Medications
buPROPion HCl Atorvastatin Calcium Medication List reviewed and reconciled with the patientPast Medical History
- High cholesterol
Vitals
RR
16.0
HR
63.0
BP
111/74
BMI
26.38
WEIGHT
200 lbs
HEIGHT_IN
73.0
Clinical Summary (HPI)
General Urology: 45 year old female, new patient, presents for assessment of microscopic hematuria. He recently went to a nephrologist for elevated Cr. The nephrologist did not recommend any intervention at this time. He notes that in his youth, he would notice his urine as tea colored when he was dehydrated. As he got older, he hydrated more, and his urine would not be as dark. He notes frequency, urgency, and nocturia when he is well hydrated. Urinary symptoms did not become bothersome until he got older. He endorses daily fluid input of 60-70oz. He had imaging done at Sentara last week.
Raw Note (de-identified preview)
4/13/26, 2:25 AM Print Preview
[PATIENT_NAME] DOB: [DOB] (45 yo F) Acc No. [ACCOUNT_ID] DOS: 03/17/2026
[PATIENT_NAME]
45 Y old Female, DOB: [DOB]
Account: [ACCOUNT_ID]
[ADDRESS]
Insurance: Anthem BCBS FEP
PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME]
Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge
03/17/2026 Progress Notes: [PROVIDER_NAME], MD
Reason for Appointment
1. Microscopic Hematuria
History of Present Illness
General Urology:
45 year old female, new patient, presents for assessment of microscopic hematuria. He recently went to a nephrologist for
elevated Cr. The nephrologist did not recommend any intervention at this time. He notes that in his youth, he would notice
his urine as tea colored when he was dehydrated. As he got older, he hydrated more, and his urine would not be as dark. He
notes frequency, urgency, and nocturia when he is well hydrated. Urinary symptoms did not become bothersome until he got
older. He endorses daily fluid input of 60-70oz. He had imaging done at Sentara last week.
Current Medications
Taking
buPROPion HCl 75 MG Tablet 2 tablets Orally Twice a day
Atorvastatin Calcium 10 MG Tablet TAKE 1 TABLET BY MOUTH EVERY DAY Oral
Medication List reviewed and reconciled with the patient
Past Medical History
High cholesterol.
Surgical History
Appendectomy 2012
Family History
Father: alive, skin cancer, colon cancer
Mother: alive
Social History
Recreational drug use: no.
Exercise: no.
Caffeine: yes, frequency:1 energy drink per week.
Sexually active: no.
Occupation: yes, IT Technician.
Tobacco Control (Standard)
Tobacco use: Former smoker
How long has it been since you last smoked? Greater than 10 years
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? Monthly or less (1 point)
How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 drinks (0 point)
Progress Note: [PROVIDER_NAME], MD 03/17/2026
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
Generated for Printing/Faxing/eTransmitting on: 04/12/2026 04:55 PM EDT
1/4
4/13/26, 2:25 AM Print Preview
[PATIENT_NAME] DOB: [DOB] (45 yo F) Acc No. [ACCOUNT_ID] DOS: 03/17/2026
How often did you have six or more drinks on one occasion in the past year? Less than monthly (1 point)
Points 2
Interpretation Negative
Screening
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Denies Past Hospitalization
Review of Systems
11 system Review of Systems completed in the chart and all pertinent positives and negatives reviewed with the
patient...fp.
Vital Signs
RR: 16, HR: 63, BP: 111/74 mm Hg, Ht: 73, Wt: 200 lbs, BMI: 26.38 Index.
Physical Examination
GENITOURINARY - FEMALE:
General Appearance: alert, oriented, no apparent distress.
Assessments
1.Microscopic hematuria - R31.29 (Primary)
2.Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1
Treatment
1.Microscopic hematuria
LAB: Urinalysis,