REASON FOR VISIT: The patient comes for an appointment for hematuria.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who was initially seen by Dr. John Doe for hematuria and was found to have a transitional cell carcinoma of the bladder. We then saw him and performed a cystoscopy and transurethral resection of bladder tumor 2-1/2 years ago.
The patient was supposed to follow up in three months, but eventually, he was found to have metastatic disease to his lung. The patient, at that time, was followed for an abdominal aortic aneurysm. During one of the CAT scans for this reason, he was found to have distal metastasis from his transitional cell carcinoma proven by biopsy and resection.
After that, the patient was referred to Dr. Jane Doe in consideration of possible salvage chemotherapy. The patient states that he thought that since he was followed by Dr. Jane Doe and since he had serial PET scans to monitor the response to chemotherapy, he did not need to come back and see me and so he did.
The patient has received a total of 14 cycles of chemotherapy during the last two years. Recently, he had an episode of painless gross hematuria. He comes here for further evaluation.
Today, we sent a sample of urine for analysis and cytology and then he was prepared for an office cystoscopy.
DESCRIPTION OF PROCEDURE: The patient was placed in a supine position on the operating table. Genitalia prepped and draped according to the usual sterile fashion.
A flexible cystoscope was introduced into the urethra and advanced through the prostatic urethra without difficulty. At the level of the bladder neck and on the right side of the trigone, there was evidence of papillary transitional cell carcinoma of the bladder. The left ureteral orifice was identified, but the right one could not be identified. The remaining portion of the bladder appeared free of disease.
The cystoscope was removed, and the patient was informed about the findings.
PLAN: Schedule for cystoscopy, transurethral resection of bladder tumor.
