Patient Note — 74504
progress_notes_74504_1_deid.txt
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
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[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