Urology Follow-Up Visit Note

Chief Complaint

1. Benign prostatic hyperplasia with lower urinary tract symptoms

2. Elevated prostate-specific antigen

3. Non-obstructing left renal calculus

4. Erectile dysfunction

Past Urologic History

14/11/2023: Evaluated for worsening LUTS, nocturia x 3, and borderline elevated PSA of 4.1 ng/mL. Initiated tamsulosin (Flomax®) 0.4 mg PO daily and ordered repeat PSA alongside a retroperitoneal ultrasound.

19/02/2024: Returned for imaging and lab review; ultrasound demonstrated a 4 mm non-obstructing left lower pole calculus and a 48 g prostate. Continued alpha-blocker therapy with a plan to repeat PSA in 3 months.

HPI Today

05/21/2024

The patient returns for follow-up of BPH with LUTS, elevated PSA, nephrolithiasis, and mild erectile dysfunction. Urinary stream has improved on tamsulosin (Flomax®) 0.4 mg PO daily, with nocturia reduced to 1-2 times per night and no gross hematuria, dysuria, or flank pain. He notes mild, intermittent difficulty maintaining erections sufficient for intercourse over the past 4 months.

AUA Symptom Score: 11/35; Quality of Life score: 2/6.

PVR: 42 mL via bladder scan.

PSA: 4.6 ng/mL, free PSA 14 %. Urinalysis: negative for leukocyte esterase, nitrites, and blood; microscopy 0-2 RBC/hpf.

Renal and bladder ultrasound (12/02/2024) demonstrates a stable 4 mm non-obstructing calculus in the left lower pole without hydronephrosis, and a prostate volume measuring 48 mL; images personally reviewed by me.

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

PMH: Hypertension, hyperlipidemia, BPH, nephrolithiasis. PSH: Laparoscopic cholecystectomy (2015). MEDS: tamsulosin (Flomax®) 0.4 mg PO daily, lisinopril (Prinivil®) 10 mg PO daily, atorvastatin (Lipitor®) 20 mg PO daily. ALLERGIES: NKDA. SH: Never smoker, social alcohol use (2 drinks/week), retired accountant. FH: Father with prostate cancer diagnosed at age 74.

Physical Examination

Constitutional: AAOx3 in NAD

Psychiatric: Mood and affect. Behavior. Judgment and thought content.

Abdomen: Soft, non-tender, non-distended, no CVA tenderness bilaterally.

GU: Normal circumcised phallus without plaques or lesions. Bilateral testes descended, normal size and consistency without masses. DRE reveals a symmetrically enlarged, smooth, firm prostate (~45 g) without discrete nodules, induration, or tenderness.

Labs

PSA (15/05/2024): 4.6 ng/mL (up from 4.1 ng/mL on 10/11/2023), free PSA 14 %. BMP (15/05/2024): Na 139 mmol/L, K 4.2 mmol/L, Cr 0.98 mg/dL, eGFR > 60 mL/min/1.73m². UA (21/05/2024): pH 6.0, specific gravity 1.015, negative blood, negative leukocyte esterase, negative nitrites.

Imaging

Renal and bladder ultrasound (12/02/2024): 4 mm echogenic focus in the left lower pole consistent with a non-obstructing calculus. No hydronephrosis or hydroureter. Prostate measures 48 mL. Images personally reviewed by me.

Assessment and Plan

1. Benign prostatic hyperplasia with lower urinary tract symptoms

Assessment: 66-year-old male with moderate LUTS (AUA score 11, QoL 2), significantly improved on monotherapy, with low PVR (42 mL).

Plan:

• Discussed management options including watchful waiting, continuing current medical monotherapy, adding a 5-alpha reductase inhibitor such as finasteride (Proscar®), or pursuing minimally invasive surgical therapies.
• The patient is satisfied with his current urinary symptom control and elects to continue current medical management.
• Continue tamsulosin (Flomax®) 0.4 mg PO daily.
• Reassess symptoms and PVR at next scheduled follow-up.

2. Elevated prostate-specific antigen

Assessment: Rising PSA now at 4.6 ng/mL with a lower free PSA of 14 % and a positive family history of prostate cancer. Benign DRE today. Differential diagnosis includes BPH, subclinical prostatitis, and occult prostate adenocarcinoma.

Plan:

• Discussed options including continued PSA surveillance, further biomarker testing (e.g., 4Kscore, ExoDx), multiparametric MRI of the prostate, or proceeding directly to transrectal ultrasound-guided prostate biopsy.
• The patient prefers to obtain a multiparametric MRI first to help stratify risk and guide potential targeted biopsy.
• Ordered multiparametric MRI of the prostate with and without contrast.
• Will review MRI results upon completion and schedule a targeted fusion biopsy if PI-RADS 3-5 lesions are identified.

3. Non-obstructing left renal calculus

Assessment: Asymptomatic 4 mm left lower pole renal calculus, stable on recent sonography.

Plan:

• Discussed observation with dietary modifications versus proactive surgical intervention via ureteroscopy with laser lithotripsy or shockwave lithotripsy.
• The patient elects for conservative management and observation given the absence of symptoms.
• Advised stone prevention dietary measures: increase fluid intake to achieve > 2.5 L of urine output daily, limit sodium intake, and maintain moderate dietary calcium with meals.
• Obtain a repeat renal ultrasound in 1 year to monitor stone burden.

4. Erectile dysfunction

Assessment: Mild organic erectile dysfunction, stable cardiovascular status, not on nitrate therapy.

Plan:

• Discussed treatment alternatives including oral PDE5 inhibitors, vacuum erection devices, intraurethral alprostadil, and intracavernosal injections.
• The patient desires to initiate a trial of an on-demand oral PDE5 inhibitor.
• Prescribed sildenafil (Viagra®) 50 mg PO PRN 1 hour prior to sexual activity, maximum 1 dose per day.
• Counselled on common side effects (flushing, headache, dyspepsia) and strict contraindication with nitrates.

Orders and Follow Up

Ordered multiparametric MRI of the prostate with and without contrast. Prescribed sildenafil (Viagra®) 50 mg PO PRN. Follow up in 6 weeks to review MRI results and discuss next steps regarding prostate biopsy, or in 6 months for routine LUTS/stone surveillance if MRI is negative.

Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit before this encounter. All questions were answered. The patient understands that use of AI-assisted tools may be declined at future visits.