Note for Cameron Carre on 7/22/05 - Chart 21875
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- Arabella Harrison
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1 Note for Cameron Carre on 7/22/05 - Chart Date of Last Physical Exam: 09/18/2002, New patient Date of Birth: 05/16/1941 Age: 61 Marital status of patient is: married. The number of children the patient has is 4. Chief Complaint (1/1): This 61 year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. HPI for Elevated PSA: The PSA was done on 12/15/2004. The patient denies having a prior elevated PSA. The patient denies having had an evaluation for elevated PSA in the past. The patient denies having prior history of prostate problems. The patient denies current urinary tract problems. The patient does not have hematuria. The patient does have dysuria. The patient does have a family history of prostate cancer. Father has history of prostate cancer. Timing (onset/frequency): Onset was 6 months ago. Allergies: Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia. Medication History: Patient is not currently taking any medications. Past Medical History: Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems. Past Surgical History: Patient admits past surgical history of appendectomy in Social History: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. Family History: Patient admits a family history of cancer of prostate associated with father and gout attacks associated with father. Review of Systems: Unremarkable with exception of chief complaint. Physical Exam: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6 Patient is a pleasant, 61 year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus. Oriented to person, place and time. Head: Inspection of head and face shows normocephalic. Eyes: Pupil exam reveals round and equally reactive to light. Ears, Nose and Throat: within normal limits; no lesions; no thyroid hypertrophy appreciated. Neck: Neck exam reveals structure as supple. Respiratory: Assessment of respiratory effort reveals even and nonlabored respirations and AP diameter appears within normal limits. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted. Cardiovascular: Heart auscultation reveals rate is regular and rhythm is regular. Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness. Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated. Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, hemorrhoids, or tenderness noted. Scrotum: no lesions, no hydrocele or varicocele, no scrotal skin fixation and no varicosities. Epididymis: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness, symmetrical bilaterally. Testes: symmetrical; normal lie, no abnormalities, tenderness, hydrocele, or masses noted. Urethral Meatus: on the glans in the orthotic position, no abnormalities; no hypospadias, lesions, polyps, or discharge noted. Penis: within normal size for adult male, no phimosis or paraphimosis, no Peyronie's plaque and no lesions. Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted. Digital Rectal Exam: no rectal lesions appreciated, sphincter tone is within normal limits, the bulbocavernosus reflex is present. The margins of the prostate are intact, no lesions are appreciated, and central groove is preserved. The prostate is of normal consistency and nontender. The size of the prostate is estimated to be 60 grams. Extremities: Extremities have full range of motion with no evidence of active articular disease. Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed. Neurological/Psychiatric: Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation. No localizing signs. Sensations are intact. Test Results: No tests to report at this time.
2 Impression: Elevated prostate specific antigen (PSA). Plan: Cystoscopy in the office. Diagnostic & Lab Orders: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered total prostate specific antigen (PSA). Ordered ultrasound of prostate. Counseling: I have discussed the findings of this evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP with biopsy surgical procedure; risks, complications, benefits, and alternative measures discussed. The risks of the biopsy procedure including but not limited to sepsis, hemorrhage, hematuria, hematochezia, rectal pain, hematospermia, false positives and false negatives, possible need of repeat biopsies, and rectal injury were all discussed, understood, and accepted by the patient. There are no activity restrictions. Instructed patient to avoid caffeinated or alcoholic beverages and excessively spiced foods. The patient fully understands the consequences of the biopsy as well as not complying with recommendations. The patient understands that it is the responsibility of the patient to complete all prescribed medications, all recommended testing, including but not limited to, laboratory studies and imaging. The patient further understands the need to keep all scheduled follow-up visits and to inform the office immediately of any changes in their medical condition. The patient understands that the success of treatment in large part depends on the patient's willingness to complete the therapeutic regimen and to work in partnership with the designated health-care providers. Questions answered. The patient agrees and understands the risks, options and alternatives and wishes to proceed. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at Scheduling: Return to clinic in 1 month(s). Prescriptions: Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No Patient Instructions: Patient completed benign prostatic hyperptrophy questionnaire Dr. Urologist, M.D.
3 7/22/05 A. General Practitioner 1025 Ashworth Road, Suite 222 West Des Moines, IA Dear Dr. General Practitioner: Cameron Carre was seen in my office for evaluation following your initial referral. Thank you again for allowing me to participate in the care of your patients. In an attempt to provide your patients with quality patient care through improved communication, the following represents my notes from their last office visit: Date of Last Physical Exam: 09/18/2002, New patient Date of Birth: 05/16/1941 Age: 61 Marital status of patient is: married. The number of children the patient has is 4. Chief Complaint (1/1): This 61 year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. HPI for Elevated PSA: The PSA was done on 12/15/2004. The patient denies having a prior elevated PSA. The patient denies having had an evaluation for elevated PSA in the past. The patient denies having prior history of prostate problems. The patient denies current urinary tract problems. The patient does not have hematuria. The patient does have dysuria. The patient does have a family history of prostate cancer. Father has history of prostate cancer. Timing (onset/frequency): Onset was 6 months ago. Allergies: Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia. Medication History: Patient is not currently taking any medications. Past Medical History: Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems. Past Surgical History: Patient admits past surgical history of appendectomy in Social History: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. Family History: Patient admits a family history of cancer of prostate associated with father and gout attacks associated with father. Review of Systems: Unremarkable with exception of chief complaint. Physical Exam: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6 Patient is a pleasant, 61 year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus. Oriented to person, place and time. Head: Inspection of head and face shows normocephalic. Eyes: Pupil exam reveals round and equally reactive to light. Ears, Nose and Throat: within normal limits; no lesions; no thyroid hypertrophy appreciated. Neck: Neck exam reveals structure as supple. Respiratory: Assessment of respiratory effort reveals even and nonlabored respirations and AP diameter appears within normal limits. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted. Cardiovascular: Heart auscultation reveals rate is regular and rhythm is regular. Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness. Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated. Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, hemorrhoids, or tenderness noted. Scrotum: no lesions, no hydrocele or varicocele, no scrotal skin fixation and no varicosities. Epididymis: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness, symmetrical bilaterally. Testes: symmetrical; normal lie, no abnormalities, tenderness, hydrocele, or masses noted.
4 Urethral Meatus: on the glans in the orthotic position, no abnormalities; no hypospadias, lesions, polyps, or discharge noted. Penis: within normal size for adult male, no phimosis or paraphimosis, no Peyronie's plaque and no lesions. Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted. Digital Rectal Exam: no rectal lesions appreciated, sphincter tone is within normal limits, the bulbocavernosus reflex is present. The margins of the prostate are intact, no lesions are appreciated, and central groove is preserved. The prostate is of normal consistency and nontender. The size of the prostate is estimated to be 60 grams. Extremities: Extremities have full range of motion with no evidence of active articular disease. Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed. Neurological/Psychiatric: Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation. No localizing signs. Sensations are intact. Test Results: No tests to report at this time. Impression: Elevated prostate specific antigen (PSA). Plan: Cystoscopy in the office. Diagnostic & Lab Orders: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered total prostate specific antigen (PSA). Ordered ultrasound of prostate. Counseling: I have discussed the findings of this evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP with biopsy surgical procedure; risks, complications, benefits, and alternative measures discussed. The risks of the biopsy procedure including but not limited to sepsis, hemorrhage, hematuria, hematochezia, rectal pain, hematospermia, false positives and false negatives, possible need of repeat biopsies, and rectal injury were all discussed, understood, and accepted by the patient. There are no activity restrictions. Instructed patient to avoid caffeinated or alcoholic beverages and excessively spiced foods. The patient fully understands the consequences of the biopsy as well as not complying with recommendations. The patient understands that it is the responsibility of the patient to complete all prescribed medications, all recommended testing, including but not limited to, laboratory studies and imaging. The patient further understands the need to keep all scheduled follow-up visits and to inform the office immediately of any changes in their medical condition. The patient understands that the success of treatment in large part depends on the patient's willingness to complete the therapeutic regimen and to work in partnership with the designated health-care providers. Questions answered. The patient agrees and understands the risks, options and alternatives and wishes to proceed. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at Scheduling: Return to clinic in 1 month(s). Prescriptions: Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No Patient Instructions: Patient completed benign prostatic hyperptrophy questionnaire If I may be of any further assistance in the care of this patient, please let me know. Sincerely, Dr. Urologist, M.D.
5 Patient Instructions for Cameron Carre on 7/22/2005 BENIGN PROSTATIC HYPERPLASIA Circle the numerical score for each question below. OVER THE LAST MONTH OR SO: 1. How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? None 0 1 time 1 2 times 2 3 times 3 4 times 4 5 or more times 5 2. How often have you had a sensation of not emptying your bladder completely after you finished urinating? 3. How often have you had to urinate again less than two hours after you finished urinating? 4. How often have you found that you stopped and started again several times when you urinate? 5. How often have you found it difficult to postpone urination?
6 6. How often have you had a weak urinary stream? 7. How often have you had to push or strain to begin urination? TOTAL SCORE: (sum of questions 1-7) Source: 2002 Griffith's 5-Minute Clinical Consult
7 Provider: Dr. Urologist, M.D. Patient: Cameron Carre, Chart Main Street West Des Moines, IA Diagnoses Treatments Billing Statement - Friday, July 22, Elevated Prostate Specific Antigen (PSA) Office or other outpatient visit - est. patient - 10 min Cystourethroscopy (Separate Procedure) Prostate Specific Antigen (PSA); Free Prostate Specific Antigen (PSA) ; Total Creatinine; Blood Culture, Bacterial; Quantitative Colony Count, Urine (Collection of venous blood by venipuncture) Referring Physician: General Practitioner Date Last Seen: 9/18/2002
8 Medical Clinic PRESCRIBER: Dr. Urologist, M.D Ashworth Road, Suite 222 TELEPHONE: (515) West Des Moines IA DEA: ===================================================================================== PATIENT: Cameron Carre TELEPHONE: ADDRESS: 123 Main Street DOB: 05/16/1941 West Des Moines, IA DATE: 7/22/2005 Rx Proscar 5 mg tablet Disp: 30 Sig: once daily Refills: 0 X DISPENSE AS WRITTEN GENERIC SUBSTITUTION PERMITTED SIGNATURE OF PRESCRIBER
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