DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: This is a (XX)-year-old female who for several months now has been experiencing urinary urgency and urinary frequency. She occasionally leaks a very small amount of urine, but not anything that she is overly concerned about. She also reports that when she is voiding, she has a decrease in sensation of voiding, but does not need to strain to empty her bladder and has no sense of incomplete emptying of her bladder. She has no history of chronic or recurrent urinary tract infections. Currently, no history of dysuria or hematuria. Medications recently changed from Celexa to Lexapro, but she did not notice any difference in her voiding symptoms at that time.
OBJECTIVE: Well-developed, well-nourished female, in no acute distress. Vital signs reviewed. Abdomen is soft and nontender. No hepatosplenomegaly or palpable masses. No evidence for inguinal adenopathy or inguinal hernia. External genitalia normal. Vagina with atrophy noted. Urethra is nontender. No mass, no discharge. No evidence for cystocele or rectocele. The patient examined supine and standing and again no evidence of prolapse. Neurologically, alert and oriented x3. Mood is normal.
Normal creatinine and normal protein-to-creatinine ratio. Bladder scan for postvoid residual is 0 mL.
ASSESSMENT:
1. Urinary urgency and frequency could be related to atrophic vaginitis or possibly overactive bladder. The description of the decreased sensation during voiding is not particularly clear to us. She does have some pelvic floor weakness, so potentially that could be a reason behind that.
2. Atrophic vaginitis.
PLAN: The patient would prefer to be conservative and does not wish to give a trial of anticholinergic medications at this time, which I think is reasonable. She will continue to monitor symptoms and avoid dietary irritants, particularly coffee, to see if her urgency and frequency will decrease. We could consider topical estrogen as another option as well. She will be in touch with us if she chooses to intervene differently.
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DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is seven years post brachytherapy. He seems to be doing well. His PSAs have always been less than 0.1. He voids with a forceful urinary stream. He has some episodes of urinary frequency and nocturia that he controls with Detrol LA.
OBJECTIVE: On physical examination, he is a pleasant, well-oriented, adult male patient, in NAD. Head and Neck: Normal. Abdominal exam shows no masses or tenderness. No inguinal lymphadenopathy. His postvoid residual is 114 mL. He has normal genitalia. Digital rectal exam revealed a firm, flat prostate. The firmness is more on the right than on the left, but no change from previous exam.
PLAN: The patient will have a PSA today. He seems to be stable and we will see him again in one year. In regard to his postvoid residual of 114 mL, we have advised him to take his time and try to empty his bladder well, to sit and use Crede to help empty his bladder.
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DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient is a (XX)-year-old gentleman who was initially seen by myself for workup for microscopic hematuria. His workup was negative, including CT scan and cystoscopy. Unfortunately, he developed a urinary tract infection with associated pyelonephritis, which led to admission. He was admitted for approximately one week and was treated successfully and discharged. He was placed on Flomax upon discharge and has been taking that for about a month. In the interim, he developed a paraphimosis, which was successfully reduced here in the clinic. The patient returns today, having been off Flomax for one week. He states his urinary symptoms have been better since he came off Flomax. He is getting up less at night now that he is off the Flomax and thinks that he did not need this medication. His postvoid residual today in clinic was measured at a value of zero. He states his urinary frequency had normalized and returned to his baseline that was present prior to cystoscopy. His incontinence has resolved. He is not having any dysuria. He has not experienced any fever or chills.
ASSESSMENT:
1. Negative workup for microscopic hematuria.
2. Resolved pyelonephritis.
PLAN: The plan is to send a urine culture off today to verify resolution of infection, and he may return on an as-needed basis. If in the future, he feels like he is having difficulty with urination, a prescription of Flomax could be tried again.
