Genitourinary Clinical Case

HPI
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient
has been experiencing this over the past two years, but for the past two weeks, the symptoms
have increased significantly. The current symptoms are similar to what he experienced in the past.
However, for the past two weeks, he has had increased nocturia, with decreased strength of urinary
flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very
troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow
and this is interfering with daily activities. He needs to pass urine four to five times every night. He has
been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work
up in the past, but now the symptoms have been increasing in severity. He believes he had a lowgrade
fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had
significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him
to seek medical help now.
PMH
Patient has not sought any medical care for this problem to date. He is being treated for hypertension
and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five
years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was
treated and then released. There are no recent hospitalizations and no surgeries.
ROS
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in
the stool. No gross hematuria.
MEDICATIONS
Cardizem 240mg daily
Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.
ALLERGIES/REACTIONS
No known drug allergies
Page 1 of 3
NSG6001 ? Advanced Nursing Practice I
?2015 South University
NSG6001 ? Advanced Nursing Practice I
Week 4: Gastroenterology Clinical Case
SOCIAL HISTORY
Patient has a master?s degree in engineering and his income is $65,000.00 per year. Though
the patient is educated, he lacks an understanding of resources available to him. Patient
has no problems with finances. He has excellent access to healthcare, but most often does
not utilize the services to the extent that is expected. He has an excellent health insurance
coverage including a prescription plan.
Patient is married and his spouse has excellent general health. He has two grown-up sons
who live with their own families. They are 35 and 37 years old, both alive and well. Although
the patient has a master?s in engineering, his knowledge of healthcare is inadequate. He
believes that he is generally healthy.
His perception of self-efficacy is adequate. He has very little stress. His support systems
include his wife and friends from work who provide him with the required emotional support.
There is no family dysfunction. The patient is high strung and an over achiever. He gets little
from social support outside the home or work.
Patient is originally from United States. He lives in a suburban setting. His resources include
his wife and the people he works with. Though there are other resources available to him, he
is not sure what they are.
HABITS
Smoking: Non smoker
Alcohol: Does not drink
Substance use: Denies substance abuse
DIET HABITS
His wife does most of the cooking. He believes that he gets adequate exercise, eats healthy,
and maintains a regular checkup regime with his physician.
WORK HABITS
He is an engineer and has always done the same work.
FAMILY HISTORY
He has one sister and one brother. Both are alive and well. There is a remote history of heart
disease among his aunts and uncles.
PHYSICAL EXAMINTAION
Vital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt: 200#;
Ht: 71?
NSG6001 ? Advanced Nursing Practice I
Week 4: Gastroenterology Clinical Case
HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border
Carotids: No bruits
Abdomen: Android obesity, non-tender
Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation.
Genital/Pelvic: Circumcised, no penial lesions, masses, or discharge.Testes are descended
bilaterally, no tenderness or masses
Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.
Neurologic: Not examined
Lab Results/Radiological Studies/EKG Interpretation
Lab Results
PSA: 6.0
CBC: WNL
Chem panel: WNL
Radiological Studies: None
EKG: None
Care Plan Template
Patient Initials: ______ Age: _______________ Sex: ___________
Subjective Data:
Client Complaints:
HPI (History of Present Illness):
PMH (Past Medical History?include current medications, any known allergies, any history of surgery or hospitalizations):
Significant Family History:
Social/Personal History (occupation, lifestyle?diet, exercise, substance use)
Description of Client?s Support System:
Behavioral or Nonverbal Messages:
Client Awareness of Abilities, Disease Process, Health Care Needs:
Objective Data:
Vital Signs including BMI:
Physical Assessment Findings:
Lab Tests and Results:
Client?s Support System:
Client?s Locus of Control and Readiness to Learn:
ICD-10 Diagnoses/Client Problems:
Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and follow-up plans):
References