Case 1 |
|
Chief Complaint |
“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 |
Subjective |
Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, dysuria. |
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:
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms?
5.
Give rationales for your each differential diagnosis.
6.
What teachings will you provide?
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.