Patient Note — 267451
progress_notes_267451_1_deid.txt
Demographics & Encounter
Patient ID267451 (PHI redacted)
Age / Gender76 / Male
Date of Service2026-04-03
ProviderNone
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerMedicare VA
Reason1. Urine retention
Diagnoses
R33.9
Retention of urine, unspecified
Medications
Pantoprazole Sodium Tradjenta(linaGLIPtin) Insulin Glargine Solostar 300 UNIT/ML Solution Pen-injector Subcutaneous Tamsulosin HCl 0.4 MG Capsule Oral Furosemide Gabapentin Azithromycin NovoLOG FlexPen(Insulin Aspart) 100 UNIT/ML Solution Pen-injector Subcutaneous Medication List reviewed and reconciled with the patientPast Medical History
- type II diabetes
Vitals
BMI
25.22
WEIGHT
186 lbs
HEIGHT_IN
72.0
Clinical Summary (HPI)
Urinary Retention: 76yM here for follow-up following urinary retention in the hospital. The patient presents today with a foley catheter in place. Urinary retention began 3/29. He was straight cath repeatedly until 3/31. Dr Gupta started him on flomax but a bladder scan revealed persistent retention, pvr 1000cc. S/p foley and referred to urology. There is also a plan for Dr Gupta to evaluate foley catheter on 4/6 Pt reports no prior AUR or LUTS --------------- The patient's previous work-up history is listed below: Treatment: n/a PSA: n/a.
Raw Note (de-identified preview)
4/16/26, 12:43 AM Print Preview
[PATIENT_NAME] DOB: [DOB] (76 yo M) Acc No. [ACCOUNT_ID] DOS: 04/03/2026
[PATIENT_NAME]
76 Y old Male, DOB: [DOB]
Account: [ACCOUNT_ID]: [PHONE] [ADDRESS]
Home: [PHONE]
Guarantor: [GUARANTOR_NAME] Insurance: Medicare VA
(Palmetto)
PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME]
Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge
04/03/2026 NP-SameDay: STELLA Y BASOAH
Reason for Appointment
1. Urine retention
History of Present Illness
Urinary Retention:
76yM here for follow-up following urinary retention in the hospital. The patient presents today with a foley catheter in place.
Urinary retention began 3/29. He was straight cath repeatedly until 3/31. Dr Gupta started him on flomax but a bladder scan
revealed persistent retention, pvr 1000cc. S/p foley and referred to urology. There is also a plan for Dr Gupta to evaluate
foley catheter on 4/6
Pt reports no prior AUR or LUTS
---------------
The patient's previous work-up history is listed below:
Treatment: n/a
PSA: n/a.
Current Medications
Taking
Pantoprazole Sodium 40 MG Tablet Delayed Release Oral
Tradjenta(linaGLIPtin) 5 MG Tablet Oral
Insulin Glargine Solostar 300 UNIT/ML Solution Pen-injector Subcutaneous
Tamsulosin HCl 0.4 MG Capsule Oral
Furosemide 20 MG Tablet Oral
Gabapentin 300 MG Capsule Oral
Azithromycin 250 MG Tablet Oral
NovoLOG FlexPen(Insulin Aspart) 100 UNIT/ML Solution Pen-injector Subcutaneous
Medication List reviewed and reconciled with the patient
Past Medical History
type II diabetes.
Surgical History
Denies Past Surgical History
Family History
Father: deceased
Mother: deceased
Progress Note: STELLA Y BASOAH 04/03/2026
Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
Generated for Printing/Faxing/eTransmitting on: 04/16/2026 03:43 AM EDT
1/3
4/16/26, 12:43 AM Print Preview
[PATIENT_NAME] DOB: [DOB] (76 yo M) Acc No. [ACCOUNT_ID] DOS: 04/03/2026
Social History
Smoking: no
Recreational drug use: no.
Exercise: no.
Caffeine: no.
Sexually active: no.
Occupation: no.
Screening
Allergies
N.K.D.A.
Hospitalization/Major Diagnostic Procedure
Urinary retention /UVA ER 03/2026
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
HR: Not Taken - Collection Device Broken, BP: Not Taken - Collection Device Broken, Ht: 72, Wt: 186 lbs, BMI: 25.22
Index.
Examination
General:
General appearance: alert, oriented, no apparent distress.
Abdomen: soft, non-tender, no mass, no hepatosplenomegaly, No CVAT.
Heart: regular rate and rhythm.
Lungs: symmetical excursion, nonlabored.
Assessments
1.Retention of urine, unspecified - R33.9 (Primary)
Treatment
1.Retention of urine, unspecified
Clinical Notes: 76yM comes in today to be evaluated for urinary retention.
He is here in the afternoon, therefore, I do not recommend TOV.
He plans to proceed with Dr Gupta in a few days.
He is requesting further workup to deetermine cause of retention.
I