This document contains information that was shared with Jacob M Reider. It may not contain the entire record from Kaiser Permanente Northwest.
Note from Kaiser Permanente Northwest
Section (CONC)
Concern
Section (IMMUNIZ)
Tobacco Smoking Status
Vital Signs
Immunizations
Care Team
Section (AMB)
Influenza Vaccine
Progress Notes
Simone L. Vernez, MD - 01/09/2026 8:00 AM PST Formatting of this note is different from the original.
UROLOGY CLINIC VISIT
UROLOGY PROBLEM LIST:
BPH with LUTS
On flomax and finasteride, added tadalafil with improvement of symptoms
Low PVRs
PSA 1.33 8/2025 (not on finasteride)
RBUS showing 81g prostate; office cystoscopy with prostate with significant intravesical median lobe
Otherwise very healthy, family medicine physician
HISTORY OF PRESENT ILLNESS:
Jacob M Reider is a 62 yrs male who is being seen in consultation in Urology clinic for discussion of his LUTS.
11/3/2025
10:13 AM 1/1/2026
6:22 AM
AUA SYMPTOM SCORE
Incomplete Empyting kp.org Almost always Less than 1 in 5 times
Frequency kp.org More than half the time About half the time
Intermittancy kp.org About half the time About half the time
Urge to Urinate kp.org About half the time Less than 1 in 5 times
Weak Stream kp.org Almost always About half the time
Straining kp.org Less than half the time Less than 1 in 5 times
Urinating at Night kp.org 2 times 2 times
Total Score kp.org 24 (Severe) 14 (Moderate)
He is a retired family doctor.
Started himself on flomax 2 years ago.
Has an episode of prostatitis. Treated with antibiotics. Resolved.
Had a PSA done at that point after resolution of his prostatitis as well as a RBUS which .
Saw another provider and was started on finasteride.
Recently met with Kristen Windom and they added daily tadalafil. Overall he has seen significant improvement of his symptoms but understands that with his prostatomegaly he may likely need a procedure in the future and comes in today to discuss this.
Notes that he wishes to avoid retrograde ejaculation.
He does pelvic floor exercises. He is quite active and healthy. His dad had BPH and had a TURP at 75; path incidentally noted to include lymphoma in the prostate. No family history of prostate cancer.
PAST MEDICAL HX:
Patient Active Problem List:
BPH (BENIGN PROSTATIC HYPERPLASIA)
NEGATIVE DNA STOOL TEST DONE OUTSIDE KP IN 2024
MEDICATIONS:
Current Outpatient Medications
Medication Instructions
Finasteride (PROSCAR) 5 mg, Oral, DAILY, for urinary symptoms
Lisinopril (PRINIVIL/ZESTRIL) 10 mg, Oral, DAILY
Rosuvastatin (CRESTOR) 10 mg, Oral, DAILY, to lower risk of heart attack and stroke
Tadalafil (CIALIS) 5 mg Oral Tab Take 1 tablet by mouth daily for urination and Erectile Dysfunction
Tamsulosin (FLOMAX) 0.4 mg, Oral, DAILY
ALLERGIES:
No Known Allergies
PAST SURGICAL HX:
Past Surgical History:
Procedure Laterality Date
ARTHROSCOPY OF KNEE
HERNIA REPAIR
FAMILY & SOCIAL HISTORY:
Reviewed at prior visit
12-point ROS (Constitutional, Skin, Heart, HEENT, GI, Chest, Endocrine, Mental Health, Urology, Vascular, Muscle/Bone, Neuro) performed and are negative except for: none
PHYSICAL EXAM:
BP 105/67 | Pulse 68
GENERAL: healthy, alert, no acute distress
LABS:
Component Value Date
NA 141 02/12/2025
K 4.5 02/12/2025
CL 104 02/12/2025
CO2 28 02/12/2025
RBS 96 02/12/2025
BUN 29 (H) 02/12/2025
CR 1.00 02/12/2025
CA 9.3 02/12/2025
ANIONGAP4 9 02/12/2025
Recent Labs
_ 08/05/25
1040
PSA 1.33
Not on finasteride
URINALYSES AND CULTURES:
Most Recent Urine Dipstick
Component Value Date
USG 1.025 11/04/2025
UPH 6.5 11/04/2025
ESTERASEWBC Negative 11/04/2025
UNITRITE Negative 11/04/2025
UPROTEIN Negative 11/04/2025
UAGLU Negative 11/04/2025
UKET Negative 11/04/2025
UABILI Negative 11/04/2025
UAHGB Negative 08/05/2025
Most Recent Urine Microscopic (verify date)
Component Value Date
UAPPEAR Clear 08/05/2025
UAHGB Negative 08/05/2025
Order Date: 08/05/25. Actual result date may vary.
URINE CULTURE W COLONY COUNT
Specimen: URINE
Result Value Ref Range
Final Report: <10, 000 cfu/mL Insignificant growth
IMAGING:
The following has been copied and pasted from RBUS 2/7/2025:
EXAM TYPE: US KIDNEYS AND URINARY BLADDER COMPLETE
EXAM DATE & TIME: 2/7/2025 11:15 AM
HISTORY: CLINICAL CONCERN: urinary retention (differential diagnosis or r/o)
WEIGHT: No weight on file.
COMPARISON: None.
TECHNIQUE: Renal and bladder ultrasound was performed.
FINDINGS:
Right kidney: 12.3 cm. No hydronephrosis, perinephric fluid or obvious calculi. No renal parenchymal thinning. Normal renal echogenicity.
Left kidney: 11.9 cm. No hydronephrosis, perinephric fluid or obvious calculi. No renal parenchymal thinning. Normal renal echogenicity.
Bladder: Prevoid urinary bladder volume 233 cc. Possible mild diffuse bladder wall trabeculation reflect mild hypertrophy. No focal bladder lesion. Both ureteral jets were documented. No dilated ureter at level of bladder. Post void bladder residual 8 4 cc. Moderate prostatomegaly indenting the base of urinary bladder compatible with BPH. Prostate 81 cc.
IMPRESSION:
1. Normal kidneys. No hydronephrosis.
2. Moderate post void bladder residual 84 cc. Equivocal mild diffuse wall trabeculation.
3. Moderate prostatomegaly.
Electronically signed by Kevin C Lacour, MD. 2/13/2025 8:22 AM
IMPRESSION:
Jacob M Reider is a 62 yrs male who is being seen in consultation in Urology clinic for discussion of outlet procedures for his symptomatic BPH.
Today we reviewed procedures offered at Kaiser Portland for treatment of benign prostatic hyperplasia. These include office based procedures such as Urolift or Rezum as well as endoscopic surgical treatments and finally robotic or open approaches for prostate tissue removal. The right procedure for each patient is dependent on multiple factors including prostate size, existing comorbidities, and tolerance of each given known side effect profile.
Rezum and Urolift are typically reserved for men with small prostates, less than 70g. The major benefits of these procedures include that they may be performed in the office and there is no retrograde ejaculation. Endoscopic approaches include transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HOLEP). Both procedures are minimally invasive and involve the endoscopic removal of prostate tissue. Both options have similar outcomes and are same day procedures. The main benefits of HOLEP is the ability to be performed on active anticoagulation or on larger than average glands, especially those over 90g, and less than 1% re-treatment rates. Finally, robotic or open procedures are reserved for very large glands.
We spent the bulk of our visit today discussing HOLEP as he had sone research on it and is interested in the procedure. We reviewed potential side effects of HOLEP including but not limited to infection, hematuria, permanent retrograde ejaculation, iatrogenic urethral or bladder injury, risk of anesthesia, delayed scar formation requiring additional intervention, and persistent bothersome urinary symptoms that may require additional therapy. We also reviewed the risk of urinary incontinence, especially in the first three months following treatment, sometimes necessitating pelvic floor physical therapy. Finally, I noted that the tissue removed during HOLEP is examined for malignancy and that approximately 25% of patients have incidental discovery of prostate cancer. This often does not require additional therapy depending on the ultimate pathology, patient factors and preferences.
PLAN:
Dr. Reider would like to consider his options, but would like to consider moving forward with HOLEP which is a great option given his >80g prostate. I will place a case request today. He knows that this might be performed by another surgeon (Hawken or Bui) as I will be going out on maternity leave.
Simone L. Vernez, M.D.
Kaiser Permanente
Department of UrologyElectronically signed by Simone L. Vernez, MD at 01/09/2026 10:41 AM PST
A Oshiro, LPN - 11/04/2025 1:30 PM PST Formatting of this note is different from the original.
Post Void Residual:
Did pt void before PVR? Yes
Method of measuring PVR Bladder Scanner
Bladder volume when test performed (in ml) 2 mL
Home Phone 518-439-3731
Work Phone 518-478-6661
Mobile 518-478-6661
Chaperone offered, patient declined. Patient consented to exam without presence of a chaperone.
BP Method: dinamap
Weight: 170 lbs as recorded in chart. Pt reports 164.5 lbs at home
Estimated body mass index is 24.48 kg/m² as calculated from the following:
Height as of 11/3/25: 5' 10" (1.778 m).
Weight as of 11/3/25: 170 lb 9.6 oz (77.4 kg).
Is patient new member? No
Medications Reviewed: Yes
Patient Prefers: Kaiser pharmacy
Visit preparation completed, including updating Care Everywhere outside medical records.
Annielani Oshiro, LPNElectronically signed by A Oshiro, LPN at 11/07/2025 4:29 PM PST Kristine Jost Windom, PA - 11/04/2025 1:30 PM PST Formatting of this note is different from the original. Images from the original note were not included.
UROLOGY NEW PATIENT EVALUATION
11/4/2025
Reason for Evaluation: BPH/LUTS
History of Present Illness
Jacob M Reider is a 62 year old male who presents with urinary symptoms and bladder discomfort.
Lower urinary tract symptoms
- Urinary symptoms present for six months, including nocturia and suprapubic pressure during urination
- Suprapubic pressure described as sharper than previously
- Daytime urinary frequency approximately every ninety minutes
- Sensation of incomplete bladder emptying, especially in the morning, often requiring multiple attempts to void
- Bladder discomfort reduced by avoiding caffeine, particularly coffee
History of prostatitis
- Prostatitis onset in January, associated with cycling without padded shorts
- Severe pain lasting two weeks
- Self-administered Bactrim and extensive use of ibuprofen during episode
- Creatinine level elevated to 1.6 during this period
- No history of nephrolithiasis
- Renal ultrasound was normal
Prostate medication management and adverse effects
- Currently taking tamsulosin and finasteride for prostate management
- Increased tamsulosin dose resulted in orthostatic symptoms, necessitating return to original dose
- Erectile function remains intact despite finasteride use
11/3/2025
10:13 AM
AUA SYMPTOM SCORE
Incomplete Empyting kp.org Almost always
Frequency kp.org More than half the time
Intermittancy kp.org About half the time
Urge to Urinate kp.org About half the time
Weak Stream kp.org Almost always
Straining kp.org Less than half the time
Urinating at Night kp.org 2 times
Total Score kp.org 24 (Severe)
Prior medical therapy: Yes
What type: finasteride and tamsulosin
History of retention: No
History of bladder stones: No
Renal insufficieny: No
Patient Active Problem List:
BPH (BENIGN PROSTATIC HYPERPLASIA)
NEGATIVE DNA STOOL TEST DONE OUTSIDE KP IN 2024
Each of these diagnoses was reviewed by me today.
Past Surgical History
Past Surgical History:
Procedure Laterality Date
ARTHROSCOPY OF KNEE
HERNIA REPAIR
Family History
Not Contributory
Social History
Social History
Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Allergies:
Patient has no known allergies.
Current Outpatient Medications
Medication Sig
Tamsulosin (FLOMAX) 0.4 mg Oral Cap Take 1 capsule by mouth daily
Rosuvastatin (CRESTOR) 10 mg Oral Tab Take 1 tablet by mouth daily to lower risk of heart attack and stroke
Finasteride (PROSCAR) 5 mg Oral Tab Take 1 tablet by mouth daily for urinary symptoms
Lisinopril (PRINIVIL/ZESTRIL) 10 mg Oral Tab Take 1 tablet by mouth daily
No current facility-administered medications for this visit.
Review of Systems:
A 14 point review of systems was performed and was negative with the following exceptions: NONE
Physical Examination:
There were no vitals taken for this visit.
Constitutional - awake, alert and oriented. History obtained from patient.
Pulmonary - minimal respiratory effort on room air
Cardiovascular - regular rate and rhythm
Gastrointestinal - abdomen is soft, non-tender and non-distended.
Genitourinary -
Penis - circumcised, no lesions
Scrotum - normal, no lesions
Urethral meatus - patent, no lesions, meatus is orthotopic, there is no discharge
Testes - smooth, normal texture,
Extr: No edema
Neuro: Non-focal.
Labs
Component Value Date
NA 141 02/12/2025
K 4.5 02/12/2025
CL 104 02/12/2025
CO2 28 02/12/2025
RBS 96 02/12/2025
BUN 29 (H) 02/12/2025
CR 1.00 02/12/2025
CA 9.3 02/12/2025
ANIONGAP4 9 02/12/2025
Component Value Date
WBCCORRECT 10.02 02/04/2025
NEUT 5.68 02/04/2025
ANC 5.68 02/04/2025
HGB 16.4 02/04/2025
HCT 47.6 02/04/2025
MCV 88.1 02/04/2025
PLT 337 02/04/2025
Recent Labs
_ 08/05/25
1040
PSA 1.33
===CYSTOSCOPY PROCEDURE NOTE===
Findings:
MEATUS: unremarkable
URETHRA: unremarkable
PROSTATE: median lobe growth expected for his age see media file
URETERAL ORIFICES: both present in normal position and shape
BLADDER MUCOSA: normal: no erythema, trabeculations, lesions or bladder tumors seen
OTHER FINDINGS: none
Additional Procedures: none
Post void residual by ultrasound:
2 ml
A) BPH (BENIGN PROSTATIC HYPERPLASIA) (primary encounter diagnosis)
NOCTURIA
P)
Orders Placed This Encounter
Tadalafil (CIALIS) 5 mg Oral Tab
DISCONTD: Ciprofloxacin Tablet 500 mg (CIPRO)
URINE DIPSTICK AUTO, POCT
IN OFFICE ULTRASOUND OF URINARY BLADDER FOR POST VOID RESIDUAL VOLUME
CYSTOURETHROSCOPY, SEPARATE PROCEDURE
-discussed mgmt options including further medical treatment options and surgical treatment options.
-he is voiding well negative PVR and would be willing to trial daily tadalafil.
-he would like a consult with a HOLEP provider in a few months as well to review options.
-median lobe on cystoscopy today and this could be managed with TURP. Will track progress.
-discussed potentially dc finasteride given low threshold and growth already noted on cysto.
Kristine Jost Windom, PA
Kaiser Permanente
Department of Urology
11/04/25Electronically signed by Kristine Jost Windom, PA at 11/07/2025 4:29 PM PST
Ashley, Anton, MA - 11/03/2025 8:10 AM PST Formatting of this note might be different from the original.
Home Phone 518-221-6005
Work Phone 518-478-6661
Mobile 518-478-6661
Chaperone offered, patient declined. Patient consented to exam without presence of a chaperone.
BP Method: dinamap
Weight: with shoes and with clothes
Estimated body mass index is 24.48 kg/m² as calculated from the following:
Height as of this encounter: 5' 10" (1.778 m).
Weight as of this encounter: 170 lb 9.6 oz (77.4 kg).
Is patient new member? No
Medications Reviewed: Yes
Patient Prefers: Kaiser and mail order pharmacy
Patient Support Tool Reviewed: Areas identified for clinician review: - Therapeutic Care Gaps.
The following care gaps have been identified: - Blood pressure check
- Immunizations: Tdap
- Labs HIV Screening. Patient informed HIV test is indicated and was given an opportunity to decline (opt out of) test.
Patient declines HIV testing. Test not ordered..
Visit preparation completed, including updating Care Everywhere outside medical records.
Ashley, Anton, CCMAElectronically signed by Ashley, Anton, MA at 11/03/2025 8:29 AM PST Tori A. Jones, MD - 11/03/2025 8:10 AM PST Formatting of this note is different from the original.
Chief Complaint
Patient presents with
ABDOMINAL PAIN
History of Present Illness
Jacob M Reider is a 62 year old male who presents with abdominal discomfort and urinary symptoms.
Suprapubic and lower abdominal pain
- Suprapubic pain present for six weeks, occurring with urge to urinate
- Pain radiates to the left lower quadrant and resembles groin pain
- Initial evaluation by sports medicine for suspected musculoskeletal etiology six months ago, with initial improvement but subsequent worsening
- Avoidance of exercise did not alleviate symptoms; intensive exercise for three weeks led to improvement
- Low FODMAP diet for two weeks resulted in significant improvement (v tincture of time)
- Symptoms began after a trip to Costa Rica, following an episode of prostatitis treated with antibiotics and a brief gastrointestinal illness
Urinary symptoms
- Frequent urination causing dissatisfaction
- Takes tamsulosin 0.4 mg for urinary symptoms + finasteride 5mg
- Doubling tamsulosin dose caused orthostatic symptoms, necessitating return to original dose
- Prostate measured at 85 grams on ultrasound
Medication tolerance and blood pressure management
- Manages blood pressure with lisinopril
- Switched from rosuvastatin to atorvastatin without significant impact on exercise tolerance
Patient Active Problem List:
BPH (BENIGN PROSTATIC HYPERPLASIA)
NEGATIVE DNA STOOL TEST DONE OUTSIDE KP IN 2024
Active Medications as of 11/03/2025:
ROSUVASTATIN 10 MG ORAL TAB, Sig: Take 1 tablet by mouth daily to lower risk of heart attack and stroke
FINASTERIDE 5 MG ORAL TAB, Sig: Take 1 tablet by mouth daily for urinary symptoms
LISINOPRIL 10 MG ORAL TAB, Sig: Take 1 tablet by mouth daily
TAMSULOSIN 0.4 MG ORAL CAP, Sig: Take 1 capsule by mouth daily
Filed Vitals:
11/03/25 0758
BP: 115/81
Pulse: 68
Resp: 20
Temp: 97.6 °F (36.4 °C)
TempSrc: Oral
SpO2: 99%
Weight: 170 lb 9.6 oz (77.4 kg)
Height: 5' 10" (1.778 m)
Physical Exam
VITALS: BP- 115/81
CHEST: Clear to auscultation bilaterally, no wheezes, rhonchi, or crackles.
CARDIOVASCULAR: Normal heart rate and rhythm, S1 and S2 normal without murmurs.
Results
RADIOLOGY
Prostate ultrasound: prostate volume 81cc
BPH W URINARY OBSTRUCTION (primary encounter diagnosis)
Orders Placed This Encounter
Male Urinary Symptoms, BPH, Urinary Retention Urology Referral
Assessment & Plan
Benign prostatic hyperplasia with lower urinary tract symptoms
Chronic BPH with LUTS, improved by 90% with lifestyle changes. Tamsulosin dose increase caused orthostatic hypotension without symptom relief. Prostate size 85g, urology referral needed.
- Continue tamsulosin 0.4 mg oral daily.
- Referred to urology for further evaluation and management.
HTN
Blood pressure controlled with lisinopril 10 mg daily. Current readings 115/81 mmHg, home readings in 110s/70s. Slightly reduced exercise tolerance possibly due to medication.
- Continue lisinopril 10 mg oral daily.
Cardio risk reduction, primary.
Managed with atorvastatin 20 mg daily. Switch from rosuvastatin did not improve exercise tolerance.
- Continue atorvastatin 20 mg oral daily.
Patient and/or others present gave consent to be recorded using documentation assistance tool.Electronically signed by Tori A. Jones, MD at 11/03/2025 8:29 AM PST
Christopher Johnson, NP - 08/05/2025 9:40 AM PDT Formatting of this note is different from the original.
Family Medicine Office Visit 8/5/2025
ASSESSMENT AND PLAN:
For the plan, please see the patient instructions in After Visit Summary. Discussed how their care team and I can work together to help them achieve their optimal physical and mental health. Instructions were printed, handed to patient, and discussed with all questions answered. Any additional details are below.
TESTICULAR PAIN (primary encounter diagnosis)
BPH (BENIGN PROSTATIC HYPERPLASIA)
SCROTAL VARICES
HYDROCELE
Orders Placed This Encounter
URINE CULTURE W COLONY COUNT
URINALYSIS, AUTOMATED W REFLEX TO MICROSCOPY AND CULTURE
PSA SCREEN
Assessment & Plan
Possible Chronic pelvic pain syndrome
Suspected CPPS, possibly post-prostatitis. Symptoms include left low abdominal pain, discomfort during urination, and left epididymis pain. Differential includes subclinical infection or atypical bacteria. NSAIDs provide symptomatic relief, indicating an inflammatory component.
- Order urinalysis and urine culture to rule out subclinical infection.
- Order PSA to monitor for inflammation or other prostate-related issues.
- Consider Voltaren gel for localized anti-inflammatory effect if needed.
- Consider referral to Urology if no identified cause in symptoms persist
Benign prostatic hyperplasia with lower urinary tract symptoms
BPH with lower urinary tract symptoms. Prostate size 85 grams, not a surgical candidate. PVR less than 100 mL. Current medications include finasteride and tamsulosin, which have improved symptoms.
- Continue finasteride and tamsulosin.
- Monitor PSA levels to assess for inflammation or other prostate-related issues.
Left varicocele
Long-standing left varicocele with left epididymis pain, possibly exacerbated by gravity. Only a little bit of enlargement noted.
- Continue wearing supportive underwear to reduce gravitational pull on the varicocele.
Discussed with patient will be contacted if there are any results needing further treatment or assessment, otherwise result to KP.org.
Jacob agreed with the plan, understood all instructions and will seek medical attention as instructed, and voiced no further questions or concerns.
Follow-up: No follow-ups on file.
Patient provided verbal consent to be recorded using documentation assistance tool.
________________________________________________________________
History of Present Illness:
Jacob M Reider is a patient of Tori A. Jones, MD. I am seeing Jacob as a cross cover provider.
Jacob M Reider is a 62 yrs old male here today for the following concerns:
Chief Complaint
Patient presents with
ABDOMINAL PAIN
LLQ, x3 months, mild but persistent
This is the scheduling note for this visit copied verbatim: "New problem - LLQ / inguinal pain - mild but persistent x 10 weeks.".
History of Present Illness
Jacob M Reider is a 62 year old male who presents with left low abdominal pain and discomfort in the inguinal area.
He experiences persistent left low abdominal pain in the inguinal area, which became noticeable during running, causing him to stop for three weeks. He wears supportive underpants to alleviate discomfort, suspecting gravity's role in the pain. He has a history of bilateral inguinal hernia repair at age five.
He experienced prostatitis five months ago, which resolved after treatment, but he continues to feel discomfort when urinating. He is on finasteride and tamsulosin. An ultrasound showed his prostate is 85 grams, and his post-void residual was less than 100. Home urine dipstick tests have been negative for blood, leukocytes, and nitrites.
He reports left epididymis pain and has a large left varicocele present for 45 years. The pain is persistent and bothers him almost daily for the past three months. Naproxen helps alleviate the pain, but he is cautious about frequent use due to previous elevated creatinine levels.
A stool test was negative. Symptoms sometimes improve after urination or bowel movements. There is no worsening of symptoms with physical or sexual activity.
Relevant past medical history, medications and allergies obtained from chart review and confirmed with patient/caregiver.
Past Medical History
Patient Active Problem List:
BPH (BENIGN PROSTATIC HYPERPLASIA)
NEGATIVE DNA STOOL TEST DONE OUTSIDE KP IN 2024
Medications:
Active Medications as of 08/05/2025:
ROSUVASTATIN 10 MG ORAL TAB, Sig: Take 1 tablet by mouth daily to lower risk of heart attack and stroke
FINASTERIDE 5 MG ORAL TAB, Sig: Take 1 tablet by mouth daily for urinary symptoms
LISINOPRIL 10 MG ORAL TAB, Sig: Take 1 tablet by mouth daily
TAMSULOSIN 0.4 MG ORAL CAP, Sig: Take 1 capsule by mouth daily
Physical Exam:
BP 133/85 (BP Location: LA-LEFT ARM, BP Patient Position: SITTING, Cuff Size: Standard Adult) | Pulse 74 | Temp 97.4 °F (36.3 °C) (Oral) | Resp 16 | Wt 165 lb 11.2 oz (75.2 kg) | SpO2 99% | BMI 23.78 kg/m²
Current weight 165 lb 11.2 oz
Last previously recorded weight 162 lb 9.6 oz on 2/12/25
Weight change is +3 lb 1.6 oz
Physical Exam
Abdominal:
Hernia: There is no hernia in the left inguinal area or right inguinal area.
Genitourinary:
Pubic Area: No rash.
Penis: Normal and circumcised.
Testes: Cremasteric reflex is present.
Right: Mass, tenderness, swelling, testicular hydrocele or varicocele not present. Right testis is descended. Cremasteric reflex is present.
Left: Testicular hydrocele and varicocele (mild tenderness) present. Mass, tenderness or swelling not present. Left testis is descended. Cremasteric reflex is present.
Epididymis:
Left: Not inflamed or enlarged. No mass or tenderness.
Lymphadenopathy:
Lower Body: No right inguinal adenopathy. No left inguinal adenopathy.
Data Review:
Christopher Johnson, NP 8/5/2025
This note has been partially dictated using Fluency voice recognition software. It has been reviewed for major content, but may contain minor mistakes due to the limitations of the software.Electronically signed by Christopher Johnson, NP at 08/05/2025 9:59 AM PDT
Tori A. Jones, MD - 04/03/2025 1:40 PM PDT Formatting of this note is different from the original.
No chief complaint on file.
Estab care
History of Present Illness
Jacob, a 61-year-old semi-retired FM doc with a history of benign prostatic hyperplasia (BPH), presents for a routine check-up. He is currently in Costa Rica and has been managing his health conditions with atorvastatin for hyperlipidemia, and tamsulosin and finasteride for BPH. He reports that his BPH symptoms have improved significantly since starting finasteride, with no nocturia or other urinary symptoms. He also mentions a recent episode of prostatitis likely triggered after peloton workout
Jacob is physically active, regularly playing pickleball. He notes that his blood pressure readings at home have been around 135/82, which is slightly higher than the recommended range. He also mentions a decrease in his HDL levels (60-->40) since starting atorvastatin and is considering switching to rosuvastatin. Using statin for risk reduction
There is no problem list on file for this patient.
Active Medications as of 04/03/2025:
FINASTERIDE 5 MG ORAL TAB, Sig: Take 1 tablet by mouth daily for urinary symptoms
TAMSULOSIN 0.4 MG ORAL CAP, Sig: Take 1 capsule by mouth daily
ATORVASTATIN 20 MG ORAL TAB, Sig: Take 1 tablet by mouth daily
Past Surgical History:
Procedure Laterality Date
ARTHROSCOPY OF KNEE
HERNIA REPAIR
Family History
Problem Relation Age of Onset
Cancer Father
lymphoma d 80
Mental Illness Brother
MDD
Father
anxiety
Sister
anxiety
Social History
Social History Narrative
Retired MD, family medicine. Works mostly in the intersection of tech and medicine.
Married.
2 kids.
Wife is dean of law school at L&C.
Askenazi
There were no vitals filed for this visit.
Physical Exam
General: WDWN male in NAD. Video visit today.
Results
Recent Labs
_ 02/12/25
1703
CHOL 191
TG 206
HDL 42
LDLCALC 108
RADIOLOGY
CAC score: 25
DIAGNOSTIC
Cologuard: Negative (Summer 2024)
AT RISK FOR CARDIOVASCULAR DISEASE (primary encounter diagnosis)
BPH (BENIGN PROSTATIC HYPERPLASIA)
No orders of the defined types were placed in this encounter.
Assessment & Plan
Elevated BP
Blood pressure averages 135/82 mmHg, above target. Open to ACE inhibitor initiation to manage hypertension and reduce cardiac risk.
- Monitor blood pressure for a week and report.
- Consider ACE inhibitor if hypertension persists.
Hyperlipidemia
On atorvastatin with decreased HDL. Considering rosuvastatin due to atorvastatin HDL impact.
Struggle w dry eye on rosuvastatin (Crestor), but might be willing to try again (was on 10mg. I'd consider 5mg)
- Monitor lipid profile and HDL after medication change.
Benign Prostatic Hyperplasia (BPH)
Well-managed on tamsulosin and finasteride with improved symptoms.
- Continue tamsulosin and finasteride.
General Health Maintenance
Colon cancer screening and Shingrix vaccination up to date.
- Update records of colon cancer screening and Shingrix vaccination.
Patient and/or others present provided verbal consent to be recorded using documentation assistance tool.
37 mins in chart/visit.Electronically signed by Tori A. Jones, MD at 04/03/2025 2:48 PM PDT
Christopher Johnson, NP - 02/12/2025 4:20 PM PST Formatting of this note is different from the original.
Family Medicine Office Visit 2/12/2025
ASSESSMENT AND PLAN:
For the plan, please see the patient instructions in After Visit Summary. Discussed how their care team and I can work together to help them achieve their optimal physical and mental health. Instructions were printed, handed to patient, and discussed with all questions answered. Any additional details are below.
URINARY FREQUENCY (primary encounter diagnosis)
PROSTATITIS
ELEVATED TRANSAMINASE
BLOOD PRESSURE ELEVATION
Orders Placed This Encounter
Finasteride (PROSCAR) 5 mg Oral Tab
Doxycycline Monohydrate (AVIDOXY) 100 mg Oral Tab
COMPREHENSIVE METABOLIC PANEL cmp ama
Assessment & Plan
Urinary Symptoms
Improvement in urinary symptoms after treatment with doxycycline and Bactrim for suspected prostatitis. Baseline urinary symptoms include occasional difficulty starting urination and nocturia.
-Extend doxycycline treatment for an additional 7 days to complete at least 3 weeks for prostatitis.
-Start trial of finasteride for urinary symptoms.
Elevated ALT and Creatinine
Noted on recent metabolic panel. Patient has stopped NSAIDs.
-Repeat metabolic panel to ensure normalization of ALT and renal function.
Elevated BP in clinic
Elevated blood pressure noted during visit, higher than patient's usual borderline readings. No history of hypertension. Not currently on anti-hypertension medication.
-Recheck blood pressure at home and during next visit.
General Health Maintenance
-Plan to update medical records and screening status.
-Follow-up appointment in one month.
Discussed with patient will be contacted if there are any results needing further treatment or assessment, otherwise result to KP.org.
Jacob agreed with the plan, understood all instructions and will seek medical attention as instructed, and voiced no further questions or concerns.
Follow-up: No follow-ups on file.
Patient provided verbal consent to be recorded using documentation assistance tool.
________________________________________________________________
History of Present Illness:
Jacob M Reider is a patient of Tori A. Jones, MD. I am seeing Jacob as a cross cover provider.
Jacob M Reider is a 61 yrs old male here today for the following concerns:
Chief Complaint
Patient presents with
FOLLOW UP CARE
Labs, imaging results
This is the scheduling note for this visit copied verbatim: "follow up".
History of Present Illness
The patient, a retired healthcare professional, presents with urinary symptoms, which have returned to baseline after a course of doxycycline and Bactrim for a suspected prostatitis. The patient describes waking up at 6 AM to urinate as part of his baseline symptoms, with occasional difficulty starting urination. The patient also mentions that he has been on tamsulosin, which has helped reduce the frequency of nocturnal urination. The patient is considering starting finasteride to further manage his urinary symptoms, as confirmed by an ultrasound showing an enlarged prostate.
The patient also discusses his blood pressure, which is higher than his usual readings. The patient describes his usual blood pressure as borderline, ranging from 135 to 145 over 80 to 88. The patient is currently on atorvastatin due to increasing cardiac risk with age, as confirmed by a coronary calcium score taken last summer. The patient anticipates that he may need to start an antihypertensive medication in the future.
The following has been copied and pasted from email on 2/8/2025 from the patient:
Seeing you next week. FYI:
-
61 YO ~ retired family doc. healthy, physically active, happy - HX borderline HTN, hyperlipidemia and BPH. Meds: tamsulosin 0.4, atorvastatin 20.
-
Just moved to PDX from upstate NY. New to KP 2/1.
Wife "failed retirement" :-( and is new Dean @ Lewis & Clark Law School
-
C-19 vaxxed 6x - recent: 12/30/24, flu vax most recent 12/30/24. Shingrix x2 - 2023.
Cologard x2 - most recent 7/24
-
~ 2 weeks ago acute onset urinary frequency, pelvic discomfort, fever, u/a + WBC after Peloton ride. Started TMP/SMX and NSAIDs dx acute prostatitis. Sx improved some after 5 days ==>
video visit with Lila Statz: changed to doxy. Labs ok 'cept BUN/Creat and AST a bit high. CBC a bit funky. d/c NSAIDs. FIT test @ home neg RBC. U/S on 2/7: PVR of 85cc and prostate 81g. No hydronephrosis.
My thinking now is: repeat CMP & CBC, start finasteride 5mg qd, consider urology @ some point, not urgent. Looking forward to meeting you - open to ideas / thoughts/ etc.
- Jacob
Relevant past medical history, medications and allergies obtained from chart review and confirmed with patient/caregiver.
Past Medical History
There is no problem list on file for this patient.
Medications:
Active Medications as of 02/12/2025:
TAMSULOSIN 0.4 MG ORAL CAP, Sig: Take 1 capsule by mouth daily
ATORVASTATIN 20 MG ORAL TAB, Sig: Take 1 tablet by mouth daily
FINASTERIDE 5 MG ORAL TAB, Sig: Take 1 tablet by mouth daily for urinary symptoms
DOXYCYCLINE MONOHYDRATE 100 MG ORAL TAB, Sig: Take 1 tablet by mouth 2 times a day for 7 days every morning and evening with food for 7 additional days for infection
Physical Exam:
BP 144/94 (BP Location: LA-LEFT ARM, BP Patient Position: SITTING) | Pulse 78 | Temp 97.8 °F (36.6 °C) (Oral) | Resp 16 | Ht 5' 10" (1.778 m) | Wt 162 lb 9.6 oz (73.8 kg) | SpO2 99% | BMI 23.33 kg/m²
Current weight must be recorded in Vital Signs section
of Visit Navigator to calculate a weight change
Physical Exam
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance.
HENT:
Head: Normocephalic and atraumatic.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds. No murmur heard.
No friction rub. No gallop.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.
Chest:
Chest wall: No tenderness.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Data Review:
Component Value Date
WBCCORRECT 10.02 02/04/2025
NEUT 5.68 02/04/2025
ANC 5.68 02/04/2025
HGB 16.4 02/04/2025
HCT 47.6 02/04/2025
MCV 88.1 02/04/2025
PLT 337 02/04/2025
Component Value Date
NA 140 02/04/2025
K 4.6 02/04/2025
CL 103 02/04/2025
CO2 28 02/04/2025
ANIONGAP4 9 02/04/2025
RBS 108 02/04/2025
BUN 30 (H) 02/04/2025
CR 1.20 02/04/2025
GFR 69 02/04/2025
TBILI 0.4 02/04/2025
PROT 7.8 02/04/2025
ALB 3.88 02/04/2025
AST 35 02/04/2025
ALT 59 (H) 02/04/2025
ALKP 98 02/04/2025
CA 9.1 02/04/2025
Christopher Johnson, NP 2/12/2025
This note has been partially dictated using Fluency voice recognition software. It has been reviewed for major content, but may contain minor mistakes due to the limitations of the software.Electronically signed by Christopher Johnson, NP at 02/12/2025 5:31 PM PST
Lila A. Statz, MD - 02/04/2025 10:00 AM PST Formatting of this note is different from the original.
Virtual Cross Coverage Visit Note
Date of Service 2/4/2025
Assessment / Plan
PROSTATITIS
- URINALYSIS, AUTOMATED W REFLEX TO MICROSCOPY AND CULTURE; Future; Expected date: 02/04/2025
- CBC W AUTOMATED DIFFERENTIAL; Future; Expected date: 02/04/2025
- COMPREHENSIVE METABOLIC PANEL (NA,K,CL,CO2,BUN,CR, GLUC,CA,ALB,TBILI,TPROT,ALT,AST,ALKP); Future; Expected date: 02/04/2025
- Doxycycline Monohydrate (AVIDOXY) 100 mg Oral Tab; Take 1 tablet by mouth every morning and evening for 10 days with food for infection
BPH (BENIGN PROSTATIC HYPERPLASIA)
URINARY RETENTION
- US KIDNEYS AND URINARY BLADDER COMPLETE; Future; Expected date: 02/04/2025
Assessment & Plan
Prostatitis
Symptoms of urinary retention and discomfort after a Peloton ride without padded shorts. Partial response to Bactrim and NSAIDs. Positive leucocyte esterase on urine dipstick.
-Order urinalysis and renal function tests.
-Change antibiotic to Doxycycline.
-Order renal scan to rule out hydronephrosis.
-Order post-void residual (PVR) measurement.
Benign Prostatic Hyperplasia (BPH)
On Tamsulosin for about a year.
-Continue Tamsulosin.
Hypertension and Hyperlipidemia
Borderline hypertension and hyperlipidemia, on Atorvastatin.
-Continue Atorvastatin.
Follow-up
In-person appointment scheduled in April. Plan to arrange an earlier appointment for PVR measurement.
Disposition: Home
Return precautions and follow up indications reviewed.
Subjective
Referral Source: kp.org
History of present illness:
61 yrs male presenting for a video appointment.
History of Present Illness
Mr. Ryder, a retired family doctor, presents with urinary symptoms that he believes are due to prostatitis. He has a history of BPH and has been on tamsulosin for about a year. He also has borderline hypertension and hyperlipidemia, for which he takes atorvastatin. His symptoms began about a week ago after a Peloton workout without his usual padded shorts. The following morning, he found it difficult to urinate and felt generally unwell throughout the day. He also noticed that he was urinating in smaller amounts than usual. He has been on Bactrim for a week, which has led to about a 40% improvement in his symptoms. However, he still experiences discomfort in his lower abdomen, likening it to the feeling of being kicked in the balls. He also believes he has urinary retention, estimating his post void residual to be between 100-200 CCs. He has been taking NSAIDs, which he believes have been the most helpful in managing his symptoms.
Relevant past medical history, medications and allergies obtained from chart review and confirmed with patient/caregiver.
Objective
Patient is speaking in full sentences.
Mood and behavior appropriate.
No signs of distress.
Physical Exam
Labs / Imaging reviewed:
No results found for this or any previous visit (from the past 1008 hour(s)).
No image results found.
All participants in today's visit provided verbal consent to be recorded using documentation assistance tool.
Video Visit: Everything worked.
Electronically Signed by:
Lila A. Statz, MD
Patient and/or others present provided verbal consent to be recorded using documentation assistance tool.Electronically signed by Lila A. Statz, MD at 02/04/2025 10:20 AM PST
History of Immunization
Patient Instructions Kristine Jost Windom, PA - 11/04/2025 1:30 PM PST Formatting of this note is different from the original.
Urology Department
Care Instructions After Your Cystoscopy
You had a cystourethroscopy (looking in the bladder with the light) procedure today.
The following instructions are general guidelines to promote a safe and uneventful recovery from your procedure. Please follow your surgeon’s specific instructions if applicable.
GENERAL
Unless you are on a fluid restricted diet prescribed by your physician, drink 2-3 quarts of liquids a day.
You may notice some burning with urination, as well as the sensation of needing to urinate more frequently.
You may also experience a small amount of blood in the urine for the first 24-48 hours; do not worry about this unless the urine is the color of burgundy wine or there are jelly-like clots obstructing the flow of urine.
Notify your physician or After Hours Advice for any of the following reasons:
If you are unable to urinate within 6 hours of drinking.
Your urine has blood clots or is the color of burgundy wine.
Any signs of infection: temperature 101° F or chills.
Urinary burning, tenderness or frequency continuing past 2 days (unless you have a stent).
Severe discomfort.
Any questions or concerns.
Urology Department Advice Phone Numbers:Electronically signed by Kristine Jost Windom, PA at 11/04/2025 2:20 PM PST
Patient Instructions Christopher Johnson, NP - 08/05/2025 9:40 AM PDT Formatting of this note is different from the original. Images from the original note were not included.
Jacob,
It was a pleasure providing care for you today.
VISIT SUMMARY:
You came in today with concerns about left low abdominal pain and discomfort in the inguinal area. We discussed your symptoms, including your history of bilateral inguinal hernia repair, prostatitis, and left varicocele. We reviewed your current medications and recent test results.
YOUR PLAN:
-POSSIBLE CHRONIC PELVIC PAIN SYNDROME: Chronic pelvic pain syndrome (CPPS) is a condition that causes persistent pain in the pelvic region, possibly due to inflammation or infection. We will order a urinalysis and urine culture to check for any hidden infections and a PSA test to monitor for inflammation or other prostate-related issues. If needed, you can use Voltaren gel for localized pain relief.
-BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS: Benign prostatic hyperplasia (BPH) is an enlarged prostate gland that can cause urinary symptoms. Your prostate size is 85 grams, and you are currently taking finasteride and tamsulosin, which have helped improve your symptoms. We will continue these medications and monitor your PSA levels to check for any inflammation or other issues.
-LEFT VARICOCELE: A varicocele is an enlargement of the veins within the scrotum, which can cause pain and discomfort. You have a long-standing left varicocele, and we recommend continuing to wear supportive underwear to help reduce the discomfort caused by gravity.
INSTRUCTIONS:
Please follow up with the urinalysis, urine culture, and PSA test as discussed. Continue taking your current medications and wearing supportive underwear. If you experience any new or worsening symptoms, please contact our office.
Lab and/or Radiology:
Please go to the Lab for blood and urine testing.
Follow-up:
If symptoms worsen or do not improve
Please ensure you are arriving and checking in for your appointments at least 15 minutes before the start of the appointment. This helps us get you into a room to start your appointment on time to address your concerns.
It was a pleasure to see you Jacob. Thank you for allowing me and our team the privilege of caring for you today. You are the reason that we are here and we hope that your health care concerns were addressed to your satisfaction and that you were provided with the excellent service that you deserve. If you have any further questions or concerns, please do not hesitate to contact the office.
You may receive a survey after today's visit. I would ask that you take the opportunity to complete the survey and let us know what we are doing well and what we can do to improve our service.
Take care,
Christopher Johnson, NP
Patient Education
Inguinal Hernia: Care Instructions
Your Care Instructions
An inguinal hernia occurs when tissue bulges through a weak spot in your groin area. You may see or feel a tender bulge in the groin or scrotum. You may also have pain, pressure or burning, or a feeling that something has "given way."
Hernias are caused by a weakness in the belly wall. The bulge or discomfort may occur after heavy lifting, straining, or coughing. Hernias do not heal on their own, and they tend to get worse over time.
If your hernia does not bother you, you most likely can wait to have surgery. Your hernia may get worse, but it may not. In some cases, hernias that are small and painless may never need to be repaired.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
How can you care for yourself at home?
Take pain medicines exactly as directed.
If the doctor gave you a prescription medicine for pain, take it as prescribed.
If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
Use proper lifting techniques, and avoid heavy lifting if you can. To lift things more safely, bend your knees and let your arms and legs do the work. Keep your back straight, and do not bend over at the waist. Keep the load as close to your body as you can. Move your feet instead of turning or twisting your body.
Lose weight if you are overweight.
Include fruits, vegetables, legumes, and whole grains in your diet each day. These foods are high in fiber and will make it easier to avoid straining during bowel movements.
Do not smoke. Smoking can cause coughing, which can cause your hernia to bulge. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
When should you call for help?
Call your doctor now or seek immediate medical care if:
You have new or worse belly pain.
You are vomiting.
You cannot pass stools or gas.
You cannot push the hernia back into place with gentle pressure when you are lying down.
The area over the hernia turns red or becomes tender.
Watch closely for changes in your health, and be sure to contact your doctor if you have any problems.
Where can you learn more?
Go to https://kp.org/health
Enter J063 in the search box to learn more about "Inguinal Hernia: Care Instructions."
Current as of: October 19, 2023
Content Version: 14.3
© 2024 Ignite Healthwise, LLC.
Care instructions adapted under license by your healthcare professional. If you have questions about a medical condition or this instruction, always ask your healthcare professional. Ignite Healthwise, LLC, disclaims any warranty or liability for your use of this information.Electronically signed by Christopher Johnson, NP at 08/05/2025 9:57 AM PDT
Patient Instructions Christopher Johnson, NP - 02/12/2025 4:20 PM PST Formatting of this note might be different from the original.
Jacob,
It was a pleasure providing care for you today.
VISIT SUMMARY:
During today's visit, we discussed your urinary symptoms, blood pressure, and general health maintenance. Your urinary symptoms have improved after treatment, but we will extend your medication and start a new one to help manage your symptoms further. We also noted elevated liver and kidney function tests, and we will repeat these tests to ensure they normalize. Additionally, we discussed your blood pressure, which was higher than usual, and we will monitor it closely. Lastly, we reviewed your general health maintenance and scheduled a follow-up appointment.
YOUR PLAN:
-URINARY SYMPTOMS: Your urinary symptoms have improved after treatment with doxycycline and Bactrim for suspected prostatitis. Prostatitis is an inflammation of the prostate gland. We will extend your doxycycline treatment for an additional 7 days and start a trial of finasteride to help manage your symptoms further. Finasteride is a medication that can help reduce the size of your prostate and improve urinary flow.
-ELEVATED ALT AND CREATININE: We noted elevated levels of ALT and creatinine in your recent metabolic panel. ALT is a liver enzyme, and creatinine is a waste product filtered by the kidneys. Elevated levels can indicate liver or kidney issues. You have stopped taking NSAIDs, which can affect these levels. We will repeat the metabolic panel to ensure your liver and kidney functions return to normal.
-ELEVATED BLOOD PRESSURE IN CLINIC: Your blood pressure was higher than your usual readings during today's visit. Hypertension is high blood pressure, which can increase the risk of heart disease and stroke. We will recheck your blood pressure at home and during your next visit to monitor it closely.
-GENERAL HEALTH MAINTENANCE: We reviewed your general health maintenance, including updating your medical records and screening status. Keeping these up to date is important for your overall health. We have scheduled a follow-up appointment in one month to continue monitoring your health.
INSTRUCTIONS:
Please continue taking doxycycline for an additional 7 days and start the trial of finasteride as discussed. Monitor your blood pressure at home and record the readings. We will repeat your metabolic panel to check your liver and kidney functions. Your follow-up appointment is scheduled for one month from now.
Medications:
Go to Pharmacy to pick up your medications.
Mail Order Pharmacy: If you don't need your medication today, I encourage you to order it through our mail-order pharmacy. Sign on to kp.org or the KP app and click Pharmacy center or call 1-800-548-9809. Most prescriptions arrive in 2-3 days. Most members get 3 months of medication for the price of 2.
Lab and/or Radiology:
Please go to the Lab for blood testing
Follow-up:
Office visit as scheduled on 4/3/2025 wit Dr Tori Jones
Please ensure you are arriving and checking in for your appointments at least 15 minutes before the start of the appointment. This helps us get you into a room to start your appointment on time to address your concerns.
It was a pleasure to see you Jacob. Thank you for allowing me and our team the privilege of caring for you today. You are the reason that we are here and we hope that your health care concerns were addressed to your satisfaction and that you were provided with the excellent service that you deserve. If you have any further questions or concerns, please do not hesitate to contact the office.
You may receive a survey after today's visit. I would ask that you take the opportunity to complete the survey and let us know what we are doing well and what we can do to improve our service.
Take care,
Christopher Johnson, NPElectronically signed by Christopher Johnson, NP at 02/12/2025 5:28 PM PST Electronically signed by Christopher Johnson, NP at 02/12/2025 5:29 PM PST
Patient Instructions Lila A. Statz, MD - 02/04/2025 10:00 AM PST Formatting of this note might be different from the original.
Jacob,
It was a pleasure providing care for you today.
Here is our Treatment Plan:
VISIT SUMMARY:
Mr. Ryder, during your visit today, we discussed your recent urinary symptoms, which you believe are due to prostatitis. You have a history of benign prostatic hyperplasia (BPH) and have been taking tamsulosin for about a year. You also have borderline hypertension and hyperlipidemia, for which you take atorvastatin. Your symptoms began about a week ago after a Peloton workout without padded shorts, leading to difficulty urinating and general discomfort. You have been on Bactrim for a week with partial improvement. We discussed your current symptoms and planned the next steps for your treatment.
YOUR PLAN:
-PROSTATITIS: Prostatitis is an inflammation of the prostate gland that can cause urinary symptoms and discomfort. We will change your antibiotic to Doxycycline and order a urinalysis and renal function tests. Additionally, we will arrange a renal scan to rule out any kidney issues and measure your post-void residual (PVR) to assess urinary retention.
-BENIGN PROSTATIC HYPERPLASIA (BPH): BPH is an enlargement of the prostate gland that can cause urinary problems. You should continue taking Tamsulosin as prescribed to help manage your symptoms.
-HYPERTENSION AND HYPERLIPIDEMIA: Hypertension is high blood pressure, and hyperlipidemia is high cholesterol levels. You should continue taking Atorvastatin as prescribed to manage these conditions.
INSTRUCTIONS:
Please continue taking your medications as prescribed. We have scheduled an in-person appointment for April, but we will arrange an earlier appointment for your post-void residual (PVR) measurement. Make sure to complete the urinalysis, renal function tests, and renal scan as ordered. If you experience any worsening of symptoms or new issues, please contact our office immediately.
Take care,
Lila A. Statz, MDElectronically signed by Lila A. Statz, MD at 02/04/2025 10:20 AM PST
Annotation Comment
Telephone Encounter - Simone L. Vernez, MD - 03/11/2026 11:58 AM PDT Formatting of this note might be different from the original.
Noted. Thank you.Electronically signed by Simone L. Vernez, MD at 03/11/2026 11:58 AM PDT Telephone Encounter - Teresa M. Villalobos, MA - 03/11/2026 11:43 AM PDT Formatting of this note might be different from the original.
Pt changing insurance case canceled.
Teresa M Villalobos Urology/Pain Clinic Surgery SchedulerElectronically signed by Teresa M. Villalobos, MA at 03/11/2026 11:52 AM PDT
Telephone Encounter - A Oshiro, LPN - 11/05/2025 3:34 PM PST Formatting of this note is different from the original.
A/R: Pt contacted via phone to schedule. Pt agreed to appointment date, time and location.
Upcoming Appointments
Date / Time Provider Department Dept Phone Special Notes
1/22/2026 3:00 PM (Arrive by 2:45 PM) Simone L. Vernez Sunnybrook Urology 503-571-4177
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
S: Call outgoing.
B: Pt to be scheduled with Dr. Vernez or Dr. Hawken for consult per K. Windom, PA.Electronically signed by A Oshiro, LPN at 11/05/2025 3:36 PM PST
Telephone Encounter - Kendra L. Downs, MA - 02/04/2025 11:12 AM PST Formatting of this note is different from the original.
R: Patient informed and agrees
Upcoming Appointments
Date / Time Provider Department Dept Phone Special Notes
2/12/2025 4:20 PM (Arrive by 4:05 PM) Christopher Johnson East Interstate Family Medicine 800-813-2000
4/3/2025 1:40 PM Tori A. Jones East Interstate Family Medicine 800-813-2000 Video Visit Evolution (Zoom)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
S: Call incoming.
B: Patient requesting an appointment for follow up.
The following has been copied and pasted from telephone encounter on 2/4/25 by Lila A. Statz, MD:
Please call and schedule an appointment.
Patient had a Virtual Cross Coverage visit and I recommend that they be evaluated further.
Reason for appointment: patient needs post-void residual ultrasound in office for urinary retention and to go over labs that I ordered today
Appointment with: PCP or any provider
Appointment timeframe: In 1-2 weeks or first available
Appointment type: In-person
Labs/imaging needed prior to appointment: No
If no appointment can be found, offer Urgent Care: No, please schedule the next soonest available appointment.
A: Request completed.
PST to be discussed at above appointment.Electronically signed by Kendra L. Downs, MA at 02/04/2025 11:15 AM PST Telephone Encounter - Lorie Ann McCoy, MA - 02/04/2025 10:23 AM PST Formatting of this note might be different from the original.
R: Attempted to call patient at numbers listed in demographics. Message left to call 855-327-5513
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
S: Call outgoing.
B: Message left for a return call. When patient calls back please schedule an office visit.
Reason for appointment: patient needs post-void residual ultrasound in office for urinary retention and to go over labs that I ordered today
Appointment with: PCP or any provider
Appointment timeframe: In 1-2 weeks or first available
Appointment type: In-person
Labs/imaging needed prior to appointment: No
If no appointment can be found, offer Urgent Care: No, please schedule the next soonest available appointment.
A: Request completed.
Unable to review PST at this time Member not available
Good morning, Jacob,
My name is Lorie and I am a MA with your healthcare team. I am sorry that I missed you today when I called regarding getting you scheduled for an office appointment. Please contact us at 855-327-5513.
Your overall health is important to us. Please see the recommendations from your provider, regarding any preventative care you may be due for, online at www.kp.org/action-plan.
Be healthy. Live well. Thrive.
Have a wonderful day!
Lorie Ann McCoy, MA
How was your experience messaging your doctor or care team? Tell us your thoughts by completing this short survey. Your feedback is important to us.
The official link to the survey:
https://forms.office.com/r/RaGf1GVT2YElectronically signed by Lorie Ann McCoy, MA at 02/04/2025 10:26 AM PST Telephone Encounter - Lorie Ann McCoy, MA - 02/04/2025 10:18 AM PST Formatting of this note might be different from the original.
----- Message from Lila A. Statz, MD sent at 2/4/2025 10:16 AM PST -----
Regarding: VCC follow-up
Please call and schedule an appointment.
Patient had a Virtual Cross Coverage visit and I recommend that they be evaluated further.
Reason for appointment: patient needs post-void residual ultrasound in office for urinary retention and to go over labs that I ordered today
Appointment with: PCP or any provider
Appointment timeframe: In 1-2 weeks or first available
Appointment type: In-person
Labs/imaging needed prior to appointment: No
If no appointment can be found, offer Urgent Care: No, please schedule the next soonest available appointment.Electronically signed by Lorie Ann McCoy, MA at 02/04/2025 10:18 AM PST
Telephone Encounter - Valerie A. Peoples, CPhT - 02/06/2025 4:22 PM PST Formatting of this note might be different from the original.
Verified posted prescriptions/signed orders on file.
Per interview below patient was instructed to check KP.org when ready to order refills.
No further Pharmacy Services follow-up planned at this time.Electronically signed by Valerie A. Peoples, CPhT at 02/06/2025 4:22 PM PST Telephone Encounter - Rebecca A. Patch, CPhT - 02/05/2025 11:25 AM PST Formatting of this note might be different from the original.
Prescription information received for all copies
Medication prescription confirmed by:
outside pharmacy
Total Number of Medications: 2
Patient on all formulary medications. Prescriptions posted to patient's profile.Electronically signed by Rebecca A. Patch, CPhT at 02/05/2025 11:26 AM PST Telephone Encounter - Nicole Moua, CPhT - 02/03/2025 4:20 PM PST Formatting of this note might be different from the original.
New Member prescription information received. Information documented below.
The following information was included in referral received from patient
Patient requesting transfer from Amazon Pharmacy. Pharmacy phone number 855-745-5725 Fax: 512-884-5981
The following was copied and pasted from patient's KANA entry:
Region:
KNW
MRN-HRN:
4565180
Last Name:
REIDER
First Name:
JACOB
DateofBirth:
1963-06-26
Day Phone:
518-478-6661
Evening Phone:
518-221-6005
Mobile Phone:
518-478-6661
Email address:
Jacob@reider.us
Membership Effective Date:
2025-02-01
Total Number of Prescriptions:
2
Transfer details:
Drug Name 1: atorvastatin
Rx # 1: 6033320579
Need Timeframe 1: Not needed within 14 days
Pharmacy Name 1: Amazon Pharmacy
Pharmacy Phone Number 1: 855-745-5725
Instructions 1: 1 qd
Strength 1: 20 mg
Refills Remaining 1: Yes
Drug Name 2: Tamsulosin
Rx # 2: 6033320337
Need Timeframe 2: Not needed within 14 days
Pharmacy Name 2: Amazon Pharmacy
Pharmacy Phone Number 2: 855-745-5725
Instructions 2: 1 qd
Strength 2: 0.4 mg
Refills Remaining 2: Yes
Allergies:
No known medication allergies
Date Submitted:
02/03/2025
Time Submitted:
12:37:02 PM PST
Member Address:
636 NW MACLEAY BLVD,
Member City:
PORTLAND
Member State:
OR
Member Zip:
97210
Did tech open Care Everywhere? No, already open.
Total Number of Medications: 2
Patient referred by: KanaElectronically signed by Nicole Moua, CPhT at 02/03/2025 4:24 PM PST