Case 1 Chief Complaint (CC) “It burns when I urinate” History of Present Illnes

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 presents with dysuria and nocturia.
PMH
Benign 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.
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
Cardiovascular
S1S2 without rub or gallop S4 present
Abdomen
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
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?