Chief Complaint:

“It is getting more and more difficult to urinate. When I do urinate it seems like I can’t empty my bladder and it gets painful. I am always waking up at night to urinate too.”

History of Present Illness:

Mr. B.H. is a 52 year old white male who was referred to the urology clinic by his primary care physician after complaining of his inability to urinate, painful urination and incomplete bladder emptying. Mr. B.H. symptoms have been getting increasingly worse over the past 3 months. Most recently Mr. B.H. has noticed an increase in pain and unequal stream flow of urine while urinating. He indicates that his problems seem to be worse at night and that the pain is greater during urination after waking from sleep.

Past Medical History:

Hernia operation at birth
Left forearm break, age 14
Right knee ACL repair, age 19
Right shoulder rotator cuff repair, age 20
Hypertension diagnosis, age 41
UTI x 2, age 50 and 52

Pertinent Family History:

Father alive, age 76 years, Smoker, CAD, HTN, COPD, BPH, Prostate CA
Mother alive, age 76 years, Smoker, CAD, HTN, MI with Cardiac Stents at age 64
Brother alive, age 46, HTN
Sister alive and well at age 39 years
Father diagnosed with BPH at age of 57

Pertinent Social History:

Marine Corps Veteran with 2 tours in Iraq, 1991-1998
Has worked full-time as a real-estate agent for 15 years
Hobbies include woodwork, weight lifting, surfing and boating
Frequently spends time in the Pacific Ocean surfing, at least 3 times a week
Smoker x 20 years
Drinks approximately 3 beers 2-3 times a week
Diet high in cholesterol

Allergies:

Current Medications:

Atenolol 25 mg PO BID

Targeted Physical Assessment:

Abdomen/Scrotum/Rectum-

Blood pressure, sitting, 155/92
Bladder distended
Abdomen tender to palpation at lower quadrants
Digital rectal examination reveals enlarged prostate gland
Urine test reveals traces of blood
PSA blood test reveals 5.2 ng/ml
Initial void 75ml with post void residual ultrasound revealing 350 ml

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History