https://voicethread.com/share/13180266/
By E. Fairand and C. McIntyre
Chief Complaint:
“I’m straining and it’s getting more difficult to urinate. It always takes me a long time to start urinating. I am always waking up at night and it doesn’t feel like I am emptying my bladder completely.”
History of Present Illness:
Mr. U. Rology, a 73-year-old gentleman referred to the urology clinic with complaints of urinary frequency, urgency, painful urination and nocturia (awakening at night with the need to urinate).
Upon assessment patient answers yes to having a weak, painful stream, straining to urinate and needing to urinate frequently (every 30 minutes). The patient denies blood in the urine.
Allergies:
- NKA
Current Medications:
- Metoprolol 25 mg PO BID
Past Medical History:
- Frequent urinary tract infections (UTI)
- Noncomplicated hypertension (HTN)
- Bilateral decreased hearing.
Surgical History:
- Appendectomy (age 31)
- Wisdom Teeth Extraction (age 18)
- Tonsillectomy (age 5)
Family History:
- Father- deceased, Smoker, BPH, COPD related to smoking
- Sister #1- no significant past medical history
- Sister #2- no significant past medical history
Social History:
- Retired Postal employee
- Widowed for 5 years
- Lives at home (1 floor plan) with his dog
Laboratory Results:
- Urinalysis – positive for bacteria in urine, indicative of UTI (McCance, Huether, Brashers, & Rote, 2019)
- Prostate specific antigen – PSA blood test reveals 5.1 ng/ml (McCance, et. al., 2019).
Physical Examination:
Nurse Practitioner performs a digital rectal exam (DRE) which positively determines enlarged prostate gland (McCance, et. al., 2019). Blood pressure, sitting, 158/94, bladder distended with tender abdomen upon palpation.
Procedures:
- Bladder Ultrasound – a post void residual (PVR) of 250mL of urine retained in the bladder.
Additional Orders:
- Prostate specific antigen (PSA)
- Chemistry
Treatments:
The patient is prescribed Flomax to relieve urinary retention symptoms and a seven-day course of oral Levaquin antibiotic. The patient was scheduled for a follow-up appointment in 10-14 days for a repeat urinalysis and symptom management while taking Flomax.