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?