Patient Note — 267451

progress_notes_267451_1_deid.txt

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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 patient

Past 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