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