Learning Goal: I’m working on a nursing case study and need an explanation and answer to help me learn.
|“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.
|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.|
|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?
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.