Nursing
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?