Case #1
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Physical Exam
08/06/XX
60-year-old male with difficulty urinating. Nocturia 3 - 4 times, frequency, urgency, hesitancy, intermittence, and a feeling of incomplete bladder emptying.
Genitourinary Exam
08/06/XX
Digital rectal exam: enlarged prostate.
X-Rays & Scans
08/15/XX
Chest: Unremarkable. CT abdomen: No significant findings.
Scopes
08/19/XX
Cystoscopy: Significant obstruction by enlarged prostate.
Laboratory
08/15/XX
PSA normal, Alk phos: 123 (normal 69 - 241).
Surgical Findings
08/19/XX
TURP: Bladder outlet significantly obstructed by an enlarged prostate.
Pathological Reports
08/19/XX
Micro: Prostate: Adenocarcinoma, Gleason grade 2 + 3 = 5, in 3 of 24 total chips.
Treatment
08/19/XX
Surgery: TURP.
10/01/XX
Radiation: 10MV Photons 6 field pelvic technique, total 7380 rads to prostate.
09/15/XX
Hormone: Lupron injection.



