Urology Follow-Up Note

Short Summary

This is a 68-year-old man presenting for follow-up of LUTS secondary to BPH and rising PSA. We initiated finasteride (Proscar®) 5 mg PO daily alongside tamsulosin (Flomax®) 0.4 mg PO daily and scheduled a repeat PSA in 6 months.

Chief Complaint

The patient presents today to discuss:

1. Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH)
2. Elevated prostate-specific antigen (PSA)
3. Erectile dysfunction (ED)

Past Urological History

Mr. Miller is a 68-year-old man, a retired accountant who enjoys woodworking, referred by PCP Dr. Sarah Jenkins for BPH and elevated PSA. In 10/2023, his PSA was 3.8 ng/mL, and he was started on tamsulosin (Flomax®) 0.4 mg PO daily by APP Mark Davis. TRUS biopsy in 11/2023 was benign (12/12 cores negative), showing a 55 mL prostate. Prior cystoscopy in 12/2023 demonstrated bilobar prostatic hypertrophy without intravesical median lobe or bladder lesions.

HPI Today 05/21/2024

• LUTS have mildly progressed with increased nocturia over the past 3 months; ED remains stable on current PDE5i therapy.
• Reports nocturia x3, weak stream, and mild hesitancy; denies gross hematuria, dysuria, or urinary incontinence.
• MRI Prostate on 10/05/2024 at Mercy Imaging Center showed a 60 mL prostate, PI-RADS 2 (diffusely heterogeneous transition zone consistent with BPH, no focal suspicious lesions). I personally reviewed and independently interpreted the scan and concur with findings.
• PSA on 12/05/2024 is 4.5 ng/mL (up from 3.8 ng/mL in 10/2023); UA on 21/05/2024 is negative for blood, leukocyte esterase, and nitrites.
• AUA Symptom Score: 14 (moderate), QoL score: 3.
• PVR: 45 mL via bladder scan.
• PSA density: 0.075 ng/mL/cc.

PMH, PSH, MEDS, ALLERGIES, SH, and FH

Information reviewed with the patient and in the EMR, with changes made where appropriate.

• PMH: HTN, hyperlipidemia.
• PSH: Right inguinal hernia repair (2015).
• MEDS: lisinopril (Prinivil®) 10 mg PO daily, atorvastatin (Lipitor®) 20 mg PO daily, tamsulosin (Flomax®) 0.4 mg PO daily, sildenafil (Viagra®) 50 mg PO PRN.
• ALLERGIES: Penicillin (rash).
• SH: Never smoker, 2–3 alcoholic drinks/week.
• FH: Father had BPH; no family history of prostate or bladder cancer.

Physical Examination

Constitutional: Well-appearing, NAD, A&Ox3. Psychiatric: Normal mood and affect, cooperative behavior, intact judgment and normal thought content. GU examination: Abdomen soft, non-tender, non-distended, no CVA tenderness. Normal circumcised phallus without lesions; testes descended bilaterally without masses. DRE: ~60 g prostate, smooth, symmetric, no nodules or induration.

Assessment and Plan

This is a 68-year-old man with moderate LUTS secondary to BPH, rising PSA with recent PI-RADS 2 MRI, and stable ED.

1. Benign prostatic hyperplasia with lower urinary tract symptoms (N40.1)

• Assessment: Moderate LUTS (AUA-SS 14) with 60 mL gland on MRI and low PVR (45 mL). Suboptimal symptom control on alpha-blocker monotherapy.
• Plan: Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to continue tamsulosin (Flomax®) 0.4 mg PO daily and initiate finasteride (Proscar®) 5 mg PO daily based on patient's condition and response to treatment.
• Counseling: Discussed mechanism of 5-alpha reductase inhibitors in reducing prostate volume over 3–6 months, potential sexual side effects, and the expected 50% reduction in baseline PSA.

2. Elevated prostate-specific antigen (R97.20)

• Assessment: PSA mildly elevated at 4.5 ng/mL, likely driven by BPH given favorable PSA density (0.075 ng/mL/cc), prior negative biopsy, and recent PI-RADS 2 MRI.
• Plan: Recheck PSA in 6 months to establish a new baseline on finasteride. No further biopsy indicated at this time.
• Counseling: Reassured patient regarding low likelihood of clinically significant prostate cancer given reassuring MRI and low PSA density.

3. Erectile dysfunction (N52.9)

• Assessment: Stable and well-managed with current PRN therapy.
• Plan: Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to continue sildenafil (Viagra®) 50 mg PO PRN based on patient's condition and response to treatment.
• Counseling: Advised to avoid concomitant nitrate use and reviewed typical PDE5i side effects (flushing, headache).

Orders

• finasteride (Proscar®) 5 mg PO daily (new prescription sent to pharmacy)
• PSA total (scheduled for 11/2024)

Follow Up

Return to clinic in 6 months with repeat PSA, AUA Symptom Score, and PVR.

Short Summary

This is a 68-year-old man presenting for follow-up of LUTS secondary to BPH and rising PSA. We added finasteride (Proscar®) 5 mg PO daily to his regimen given a 60 mL gland with PI-RADS 2 MRI, and scheduled a repeat PSA in 6 months.

Consent

“Before this encounter, the patient and all other participants provided consent for using AI-assisted tools to support documentation. All questions were addressed, and the patient understands that declining AI-assisted tools remains an option.”