Patient Note — 74504

progress_notes_74504_1_deid.txt

← Back to all patients Run PA Decision for this patient →

Demographics & Encounter

Patient ID74504 (PHI redacted)
Age / Gender82 / Female
Date of Service2025-04-01
ProviderNone
FacilityPOTOMAC UROLOGY CENTER - Woodbridge
PayerMedicare VA
Reason1. ANNUAL EXAM/ LAB REVIEW

Diagnoses

C67.2 Malignant neoplasm of lateral wall of bladder
N13.30 Unspecified hydronephrosis
N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified
N39.3 Stress incontinence, female
I10 Asymptomatic hypertension

Medications

Progress Note: [PROVIDER_NAME], MD 04/01/2025 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/08/2026 06:51 AM EDT 1/5 4/8/26, 4:21 PM Print Preview [PATIENT_NAME] DOB: [DOB] (82 yo F) Acc No. [ACCOUNT_ID] DOS: 04/01/2025 Wixela Inhub(Fluticasone-Salmeterol) 500-50 MCG/ACT Aerosol Powder Breath Activated 1 puff Inhalation Twice a day Losartan Potassium Benzonatate Omeprazole Alendronate Sodium Gabapentin Azelastine HCl 0.1 % Solution Nasal Prevagen Allegra Allergy(Fexofenadine HCl) Once a day Pravastatin Sodium Multivitamin Calcium , Notes to Pharmacist: 600 + D800 DULoxetine HCl Montelukast Sodium Tylenol , Notes to Pharmacist: PRN Colace , Notes to Pharmacist: PRN Saline Mist Spray LIDOCAINE PATCH

Past Medical History

  • Diabetes mallitus
  • High cholestrol
  • High blood pressure
  • Asthma

Vitals

HR 94.0
BP 144/105
BMI 20.9
WEIGHT 118 lbs
HEIGHT_IN 63.0

Clinical Summary (HPI)

Bladder Cancer: 81 yF with history of bladder cancer and hydronephrosis presents for surveillence cystoscopy and to review cytology ----------------------. Initial Diagnosis Initial Diagnosis Yes Date of Index TURBT 03-2014 Index TURBT Pathology: HGTa Initial Intravesical therapy Yes Type of therapy Induction BCG Date of Therapy 05/27/2021 Total intravesical treatments 21 Maintainence Intravesical Therapy Induction therapy Yes , she has completed BCG protocol BCG Yes Total Number received 6 Maintenance therapy Yes BCG Yes Total Number received 15 Date of Last Intravesical Treatment 05/27/2021 Surveillance Cystoscopy Last cysto date 02/02/2022 Frequency of surveillance cysto once a year Last cysto findings normal Risk Stratification AUA Risk Stratification intermediate risk Intermediate Risk features Recurrence within 1 year, LG Ta Last TURBT Information Last TURBT Date 11/10/2016 Tumor Grade low grade Clinical Stage Ta Muscle in specimen? Yes Variant histology? none

Raw Note (de-identified preview)

4/8/26, 4:21 PM Print Preview [PATIENT_NAME] DOB: [DOB] (82 yo F) Acc No. [ACCOUNT_ID] DOS: 04/01/2025 [PATIENT_NAME] 82 Y old Female, DOB: [DOB] Account: [ACCOUNT_ID]: [ACCOUNT_ID] [ADDRESS] Home: [PHONE] Guarantor: [GUARANTOR_NAME] Insurance: Medicare VA (Palmetto) PCP: [PROVIDER_NAME] Referring: [PROVIDER_NAME], MD Appointment Facility: POTOMAC UROLOGY CENTER - Woodbridge Structured Data: How did you hear about us? : Other; Patient's temperature : 97.0; : 12/16/2021 04/01/2025 CYSTOSCOPY: [PROVIDER_NAME], MD Reason for Appointment 1. ANNUAL EXAM/ LAB REVIEW History of Present Illness Bladder Cancer: 81 yF with history of bladder cancer and hydronephrosis presents for surveillence cystoscopy and to review cytology ----------------------. Initial Diagnosis Initial Diagnosis Yes Date of Index TURBT 03-2014 Index TURBT Pathology: HGTa Initial Intravesical therapy Yes Type of therapy Induction BCG Date of Therapy 05/27/2021 Total intravesical treatments 21 Maintainence Intravesical Therapy Induction therapy Yes , she has completed BCG protocol BCG Yes Total Number received 6 Maintenance therapy Yes BCG Yes Total Number received 15 Date of Last Intravesical Treatment 05/27/2021 Surveillance Cystoscopy Last cysto date 02/02/2022 Frequency of surveillance cysto once a year Last cysto findings normal Risk Stratification AUA Risk Stratification intermediate risk Intermediate Risk features Recurrence within 1 year, LG Ta Last TURBT Information Last TURBT Date 11/10/2016 Tumor Grade low grade Clinical Stage Ta Muscle in specimen? Yes Variant histology? none Current Medications Taking Progress Note: [PROVIDER_NAME], MD 04/01/2025 Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com) Generated for Printing/Faxing/eTransmitting on: 04/08/2026 06:51 AM EDT 1/5 4/8/26, 4:21 PM Print Preview [PATIENT_NAME] DOB: [DOB] (82 yo F) Acc No. [ACCOUNT_ID] DOS: 04/01/2025 Wixela Inhub(Fluticasone-Salmeterol) 500-50 MCG/ACT Aerosol Powder Breath Activated 1 puff Inhalation Twice a day Losartan Potassium 25 MG Tablet Oral Benzonatate 100 MG Capsule Oral Omeprazole 40 MG Capsule Delayed Release Oral Alendronate Sodium 70 MG Tablet Oral Gabapentin 300 MG Capsule Oral Azelastine HCl 0.1 % Solution Nasal Prevagen Allegra Allergy(Fexofenadine HCl) 180 MG Tablet 1 tablet Swallow whole with water; do not take with fruit juices. Orally Once a day Pravastatin Sodium 20 MG Tablet Oral Multivitamin Calcium , Notes to Pharmacist: 600 + D800 DULoxetine HCl 30 MG Capsule Delayed Release Particles Oral Montelukast Sodium 10 MG Tablet Oral Tylenol , Notes to Pharmacist: PRN Colace , Notes to Pharmacist: PRN Saline Mist Spray LIDOCAINE PATCH Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution Inhalation Not-Taking Claritin Alendronate Sodium 70 MG Tablet 1 tablet 30 minutes before the first food, beverage or medicine of the day with plain water Orally Lidocaine 5 % Patch External Neurontin , Notes to Pharmacist: 100 mg PRN Lisinopril Medication List reviewed