Patient Note — 52442

progress_notes_52442_1_deid.txt

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Demographics & Encounter

Patient ID52442 (PHI redacted)
Age / Gender79 / Male
Date of Service2026-03-19
ProviderNone
FacilityTELE-POTOMAC UROLOGY CENTER-WB
PayerHumana Choice
Reason1. AQUABLATION CONSULT

Diagnoses

N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
R97.20 Elevated prostate specific antigen [PSA]
N40.2 Nodular prostate

Clinical Summary (HPI)

BPH screening: 79yM w/ hx of BPH with LUTS presents for annual exam. The patient is currently taking alfuzosin 10 mg once daily. He reports worsening urinary frequency, urgency, and urge incontinence. He is going through multiple pads daily. No GH, dysuria, or concern for UTIs. He recently had a small bowel obstruction and required an abdominal surgery and a 6-inch resection. He later experienced TIA in September 2025. He has been recovering since then. ----------------------------------- The patient's previous workup history is listed below: Treatment: Alfuzosin 10 mg QD; finasteride (d/c). Elevated PSA/Screening: Also, w/ hx elevated PSA. No recent PSAs. ------------- The patient's previous workup history is listed below: PSA: 9.91 (Feb 2024); 6.98 (April 2023); 9.1 (Feb 2023); 4.02 (Mar 2017); 4.8 (Jan 2017); 6.2 (April 2012) 4K: 2%, low risk (Mar 2017) pMRI: 75g, PIRADS 1 (April 2017) Biopsy: Benign (May 2012); HGPIN 1/12 (May 2018). Prostate biopsy Hx Previous biopsy? Yes Year of most recent biopsy 2012 Most recent biopsy result negative Post-biopsy sepsis? No Prostate MRI Date 06-2023 Prostate size (g) 105 MRI Findings PIRADs 2 lesion

Raw Note (de-identified preview)

4/21/26, 11:25 PM Print Preview [PATIENT_NAME] DOB: [DOB] (79 yo M) Acc No. [ZIP] DOS: 03/19/2026 [PATIENT_NAME] 79 Y old Male, DOB: [DOB] Account: [ACCOUNT_ID]: [ZIP] [ADDRESS], UPPER MARLBORO, MD-[ZIP] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Humana Choice (PPO) PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME] Appointment Facility: TELE-POTOMAC UROLOGY CENTER-WB 03/19/2026 TV-F/U : [PROVIDER_NAME], MD Reason for Appointment 1. AQUABLATION CONSULT History of Present Illness BPH screening: 79yM w/ hx of BPH with LUTS presents for annual exam. The patient is currently taking alfuzosin 10 mg once daily. He reports worsening urinary frequency, urgency, and urge incontinence. He is going through multiple pads daily. No GH, dysuria, or concern for UTIs. He recently had a small bowel obstruction and required an abdominal surgery and a 6-inch resection. He later experienced TIA in September 2025. He has been recovering since then. ----------------------------------- The patient's previous workup history is listed below: Treatment: Alfuzosin 10 mg QD; finasteride (d/c). Elevated PSA/Screening: Also, w/ hx elevated PSA. No recent PSAs. ------------- The patient's previous workup history is listed below: PSA: 9.91 (Feb 2024); 6.98 (April 2023); 9.1 (Feb 2023); 4.02 (Mar 2017); 4.8 (Jan 2017); 6.2 (April 2012) 4K: 2%, low risk (Mar 2017) pMRI: 75g, PIRADS 1 (April 2017) Biopsy: Benign (May 2012); HGPIN 1/12 (May 2018). Prostate biopsy Hx Previous biopsy? Yes Year of most recent biopsy 2012 Most recent biopsy result negative Post-biopsy sepsis? No Prostate MRI Date 06-2023 Prostate size (g) 105 MRI Findings PIRADs 2 lesion Current Medications Taking Aspirin 81 Progress Note: [PROVIDER_NAME], MD 03/19/2026 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/22/2026 02:25 AM EDT 1/4 4/21/26, 11:25 PM Print Preview [PATIENT_NAME] DOB: [DOB] (79 yo M) Acc No. [ZIP] DOS: 03/19/2026 B12 Zinc Calcium Metopirone amLODIPine Besylate Triamterene-HCTZ Multivitamin Fish Oil Vitamin D3 Lisinopril 40 MG Tablet TAKE 1 TABLET BY MOUTH DAILY Oral Quinapril HCl Bactrim DS(Sulfamethoxazole-Trimethoprim) 800-160 MG Tablet 1 tablet Orally Twice a day Finasteride 5 MG Tablet 1 tab(s) orally once a day Accupril Procardia XL hydroCHLOROthiazide Tamsulosin HCl 0.4 MG Capsule 1 cap(s) orally once a day Not-Taking Bactrim DS(Sulfamethoxazole-Trimethoprim) 800-160 MG Tablet 1 tablet Orally two times a day Bactrim DS(Sulfamethoxazole-Trimethoprim) 800-160 MG Tablet 1 tablet Orally Twice a day Screening Vital Signs Assessments 1.Benign prostatic hyperplasia with lower urinary tract symptoms - N40.1 (Primary) 2.Elevated prostate specific antigen [PSA] - R97.20 3.Nodular prostate - N40.2 Treatment 1.Benign prostatic hyperplasia with lower urinary tract symptoms Start Tamsulosin HCl Capsule, 0.4 MG, 1 cap(s), orally, once a day, 90 days, 90 Capsule, Refills 3 Notes: 79yM w/ hx of BPH with LUTS presents for