Neurological & Male Genitourinary Disorders

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 HxRosuvastatin 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

I ntegument good skin turgor noted, moist mucous membranes

Neuro No obvious deformities, CN grossly intact II-XII

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?

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