17 Aug Benning prostatic hyperplasia diagnosed 3 years ago
Case 1
Case 1
Chief Complaint
(CC)
“It burns when I urinate”
History of Present Illness (HPI)
A 68-year-old Caucasian male who reports to have increase on the frequency of urination with urgency for the last 5 days. He also present dysuria and nocturia.
PMH
Benning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, 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, 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, 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
Once you received your case number, answer the following questions:
- 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 your each differential diagnosis.
- What teachings will you provide?
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