Neurological & Male GI Disorders
| Case 1 | |||
| Chief Complaint
(CC) |
“It burns when I urinate” | ||
| History of Present Illness (HPI) | A 68-year-old Caucasian male who reports having an increase in the frequency of urination with urgency for the last 5 days. He also presents dysuria and nocturia. | ||
| PMH | Benning prostatic hyperplasia was diagnosed 3 years ago, UTI 6 months ago, and Lithotripsy left kidney 10 years ago. No issues after treatment | ||
| Drug Hx | Rosuvastatin 20 mg
Olmesartan 20 mg |
||
| Subjective | Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, or dysuria.
Yellowish urethral secretion. |
||
| Objective Data | |||
| VS | B/P 150/96; Pulse 89; RR 16; Temp 99.4; Ht 6,1; wt 180; | ||
| General | well-developed male, with no acute distress | ||
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. | ||
| Lungs | CTA AP&L | ||
| Card | S1S2 without rub or gallop S4 present | ||
| Abd | No tenderness normoactive bowel sounds x 4; | ||
| Rectal exam | Warm, swollen, and painful prostate gland | ||
| Integument | good skin turgor noted, moist mucous membranes | ||
| Neuro | No obvious deformities, CN grossly intact II-XII |
Answer the below questions. Note that all your responses should apply to your specific patient from your assigned case study.
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms.
Give rationales for each differential diagnosis.
What teachings will you provide?