The pt is a 64-year old referred by Dr. A for further evaluation and opinion regarding gross hematuria. The pt was previously seen in our urology clinic here may years ago due to an elevated PSA. He was to follow-up for repeat PSA blood test, but has done this with Dr. A. Last PSA blood test in March was 2017 was equal to 2.02 and stable. The pt presents at this timeframe because of recent hematuria. He was recently started on a blood thinner after a knee scope procedure and developed atrial fibrillation and will have cardiac ablation in the near future, but did develop hematuria since starting the blood thinner. The pt is on Tamsulosin chronically and is on Tamsulosin for a few years and is relatively satisfied with his voiding symptoms. He has had no interval urinary tract infections or hx of stones.

How many do I have in the HPI?

2. This is also a new patient.

The pt was referred for evaluation for hematuria as appreciated on UA taken November 2. The pt was also worked up at the time for a C&S of the urine which did grow out E.coli.baceteria. The pt was subsequently treated. It should be noted that the pt was actually hospitalized during this timeframe and subsequently discharged from the hospital apparently on the 6th of November. It is noted that this pt is a resident of a skilled nursing facility. He is a poor historian, suffers from dementia.

ROS: The pt is not able to verablize any symptoms to me. He does not state that is experiencing any fevers or chills, chest pain, or SOB. There is a hx of hematuria, however, the pt has not experienced any hematuria at this time.

Since this patient has dementia and the Dr can not get a full HPI or ROS, does this still count has a complete HPI and ROS? Any advice would be greatly appreciated!! Thanks