AI Scribe for Urologists

UROLOGY OFFICE VISIT — BPH / LUTS FOLLOW-UP
Patient: 67M, BPH on combination therapy, also has a small obstructing stone.
Date of service: 2026-04-22   Visit type: 99214 (Established, moderate MDM)

SUBJECTIVE:
3-month follow-up for BPH/LUTS on tamsulosin + finasteride. Reports improvement in stream and reduction in nocturia from 4x to 2x per night. Daytime frequency every 3 hours (was every 90 minutes). No gross hematuria.
Compliance: tamsulosin 0.4 mg PO daily at bedtime — taken consistently. Finasteride 5 mg PO daily — also consistent.
Sexual function: erections sufficient for intercourse. Notes mild reduction in ejaculate volume — counseled previously, accepts this as expected on combination therapy.
Pain: occasional left flank discomfort, mild, not radiating. No fevers, no chills, no nausea.
Last UTI: none in past 12 months.
Prior workup: Cystoscopy 2025-02 — trilobar BPH, no bladder lesions, no diverticula. Urodynamics 2025-03 — bladder outlet obstruction, normal detrusor contractility.

IPSS THIS VISIT:
- Incomplete emptying: 1
- Frequency: 2
- Intermittency: 1
- Urgency: 2
- Weak stream: 2
- Straining: 1
- Nocturia: 2
TOTAL IPSS: 11 (moderate, was 19 at 6 months ago, was 24 at baseline)
Bother (QoL): 2 of 6 (mostly satisfied — was 5 at baseline)

OBJECTIVE:
Vitals: BP 134/80, HR 68, T 36.7C, Wt 88 kg, BMI 28.7.
Gen: Well, NAD.
Abdomen: Soft, non-tender, no palpable bladder, no flank tenderness on light percussion.
GU exam: Phallus normal, testes descended bilaterally, no inguinal hernia, no scrotal masses.
DRE: Prostate 35-40 g, smooth, symmetric, firm but not nodular. Mildly enlarged left lobe. No tenderness. Sphincter tone intact.

LABS / IMAGING:
- PSA today: 1.8 ng/mL (was 2.0 six months ago, was 2.4 last year — finasteride doubling factor applied: corrected PSA approximately 3.6).
- Creatinine: 1.0, eGFR 78.
- UA: 1+ blood, no leukocyte esterase, no nitrites — likely from small known stone.
- Urine culture: pending (drawn today).
- Post-void residual (bedside US): 65 mL (was 180 mL at baseline).
- Peak flow (Qmax) home recording: 14 mL/s (was 8 mL/s at baseline).
- CT KUB (2026-04-15): 5 mm non-obstructing stone in left lower pole. No hydronephrosis. Prostate 38 g.

ASSESSMENT:
1. Benign prostatic hyperplasia with LUTS (N40.1) — significant improvement on tamsulosin + finasteride. IPSS 11 (was 24), bother 2 (was 5), PVR 65 mL (was 180), Qmax 14 (was 8). Combination therapy is working; surgical intervention not indicated at this time.
2. Asymptomatic 5 mm left lower pole renal calculus (N20.0) — non-obstructing, no infection, stable size from prior. Will manage conservatively with hydration and monitoring.
3. PSA: corrected PSA approximately 3.6 ng/mL on finasteride. Trending stable. No DRE concerns. No biopsy indicated.
4. Microscopic hematuria — most likely from known stone, but will await urine culture and reassess.
5. Cardiovascular comorbidity — well-controlled HTN on amlodipine. ASCVD 10-yr 12% — already on statin via PCP.

PLAN:
- Continue tamsulosin 0.4 mg PO at bedtime + finasteride 5 mg PO daily.
- Hydration 2.5-3 L/day for stone prevention; reduce sodium and oxalate.
- 24-hour urine collection ordered (citrate, calcium, oxalate, sodium, magnesium, uric acid, volume).
- Repeat PSA, CMP, UA, post-void residual in 6 months.
- Repeat CT KUB only if symptomatic stone progression.
- Reinforce smoke-free status (relevant to bladder cancer risk).
- Counseled patient on warning signs of stone migration (acute flank pain, hematuria, fever) — call if any.
- Discussed surgical options for the day symptoms return: TURP (gold standard, well-studied), UroLift (no thermal injury, sexual side-effect sparing), Rezum (water vapor therapy). Patient interested but not yet symptomatic enough.
- Follow-up: 6 months, sooner for symptoms.

PATIENT-FACING SUMMARY (auto-generated for after-visit handout):
Your prostate medications are working well. Your urinary symptoms are much better than at the start of treatment. The small kidney stone we found is not causing problems and we will keep watching it. Drink plenty of water, lower the salt in your diet, and call the office if you get sudden severe back pain.

Time spent: 22 minutes face-to-face. Counseling and coordination: 8 minutes (stone prevention, PSA trend, surgical options if symptoms recur).
Billing: 99214. ICD-10: N40.1, N20.0, R31.21 (asymptomatic microscopic hematuria), Z79.890 (long-term drug therapy).
Signed: PatientNotes Clinical Team (draft) — pending physician review.