Advance Health and Physical Assessment

CC:  

The patient was complaining of "urgency to urinate, weak urine stream and dribbling after urinating” 

HPI:  

A.M is a 40 years old male who went to visit a doctor complaining of urinary problems. The patient complains of having the urge to urinate, weak urine stream, and dribbling every time he finished peeing. The patient states that he has been experiencing these symptoms for several months. A.M visited the hospital three days ago, where he was given medication and requested to return to the facility for follow up. Among the symptoms presented by the patient includes frequent urination during the night. He says that he often experience the urge to urinate, which suddenly disappears the moment he reaches the toilet. He also says that he experiences sensation in the bladder the moment the bladder is not fully emptied after urinating. The patient's Prostate glands are enlarged. 

Medications : 

The following list of drugs are used to help the client empty properly through the relaxation of the Bladder and Prostate muscles. The drugs also help to prevent further enlarging of the Prostate, relieve symptoms like the difficult to start the flow of urine, need to urinate and relax the bladder and prostate muscles. They include Uroxatral (alfuzosin), Hytrin (terazosin), Cardura (doxazosin), and Rapaflo (silodosin). 

Other treatments for the urinary problem include 'antibiotic medication for bacterial prostatitis to help to treat bacterial infection. 

Often, a surgical procedure to remove the blockage caused by enlarged Prostates. 

An operation to remove prostate tissue using water jets 

PMH 

Allergie s: C old. He is not supposed to use the Prostate and cold medication together.  

Medication Intolerances: 

None 

Chronic Illnesses/Major traumas   

Diabetes and depression. The patient denies any trauma. 

Hospitalizations/Surgeries 

A.M was hospitalized for two days when he had a minor surgery to detain the bladder due to blockage in the bladder. 

Immunization: The patient received a vaccine for UTI due to recurrent urinary problems. 

Environmental : The patient denies any environmental factor that may have led to the urinary problem. He says that he uses a private bathroom, and he does not share it with any other member of the family. He also states that the toilet is always cleaned to eliminate the chances of bacteria. 

Exercise: The patient said that he takes daily walks for at least thirty minutes. 

Drinking: The client drinks occasionally and moderately. 

Sleep: The patient visits the washroom three to four times a night. He denies having problems going back to sleep after going to the toilet. 

Family History 

A.M's parents are alive and healthy. The mother, who is in her early 80s, has the problem of hypertension while the father is diabetic. The only other member of the family who has Prostate gland and urinary problems is the 55-year-old brother. The brother experiences similar symptoms as the patient. 

Social History 

A.M is a teacher and a business person at the same time. He is a father of two daughters and one son, all of who are healthy and alive. A.M lives a normal life with his wife on the family farm. Once in a while, A.M takes alcohol and smoke cigarettes. 

Safety Status: A.M is reported to be very concerned about the rules and regulations on the road. He always fastens his belt and drives at the recommended speed. 

General 

Denies experiencing changes in weight. His weight is normal as it has always been 195.7 pounds. Sometimes he experiences fever and even pain while passing urine. Denies changes in energy levels and sweating at night. 

Cardiovascular 

Denies any PND, palpitations, orthopnea, edema, and chest pain.   

Skin 

Denies any form of prolonged healing, bleeding, bruising, skin discolorations, any changes in lesions, and rashes on the skin. 

Respiratory 

Denies wheezing, pneumonia hemoptysis, coughing, dyspnea, and TB 

Eyes 

Admits wearing corrective glasses at all times and experiencing blurring on items that are far away. He denies any kind of visual changes. 

Gastrointestinal 

A.M admits to experiencing Abdominal pain, especially when passing the urine and constipation, hepatitis. However, he denies issues of ulcers, black tarry stools, hemorrhoids, N/V/D, and eating disorders. 

Ears 

Denies any ear pain, ringing, and discharge. Nevertheless, he admits to losing hearing. 

Genitourinary/Gynecological 

The patient admits to having the urge to urinate, experiencing frequency burning, and changes in urine color. 

He denies being on any contraception, being sexually active, and having contacted STDS. 

    He admits having swollen prostate glands, PSA, and urinary complains due to the burning sensation while urinating. 

Nose/Mouth/Throat 

Denies experiencing problems of Sinus, nose bleeds, dysphagia, hoarseness, dental disease, dysphagia, and throat pain. 

Musculoskeletal 

Admits experiencing Back pain by way of skeletal metastasis. He denies any joint fracture hx, swelling, and stiffness osteoporosis, 

Breast 

He denies any bumps, SBE, lumps, changes on the breast. 

Neurological 

A.M denies having Syncope, paresthesia, weakness, seizures, blackout spells, and transient paralysis. 

Heme/Lymph/Endo 

Admits to be cold intolerant. Nonetheless, he denies being HIV positive, blood transfusion hx, bruising, heat intolerance, swollen glands, night sweats, increased thirst or hunger. 

Psychiatric 

A.M denies anxiety, depression, and difficulties in sleeping, suicidal ideation/attempt, and previous dx . 

General Appearance 

A.M is a happy 40-year-old black man who lives independently. The patient appears jovial, active, and energetic. He is alert and oriented in everything that he does. He appears restress due to the frequent urinating. 

Skin 

A.M has dark skin, which is uniform without rashes and lesions. Additionally, the patient does not have bruises, injuries, or scars on his skin. His skin is supple, tight, and warm. 

HEENT 

Head: Normocephalic with well-distributed hair and without lesions. 

Eyes:  No injection within normal limits. 

Ears: Bilateral TMs glowing grey with affirmative light reflex 

Nose: Nasal mucosa is pink with no septal changes 

Neck: No occipital nodes. Pink and moist oral mucosa. 

Teeth: Healthy and in good shape 

Cardiovascular 

The heartbeat is at an average rate and rhythm. The capillary refills 2seconds and the pulse are 3+. No murmurs, clicks, rubs, or extra sound, or edema. 

Respiratory 

Respirations normal and easy 

Breast 

Deferred 

Genitourinary 

The patient says that he had one episode of blood in the urine. He states that the urge of urination increases at night. He also states that he has recurrent inability to pass urine. There is increased urgency and frequency to pass urine and the urination stream is weak. He says that he has difficulty in passing urine, and there is dribbling at the end of passing urine. He denies being sexually active. He denies feeling a burning sensation during the passage of urine. 

Musculoskeletal 

Full Rom without any joint swelling or tenderness. 

Neurological 

The patient has a clear language with a right tone. He has a good posture and balance and is able to maintain movements without the use of a walker. 

Psychiatric 

A.M is alert and always neat and collected. He maintains close eye contact while talking and always answers questions correctly. 

Lab Tests 

Urinalysis test- pending 

Urine culture test- pending 

Wet prep test- pending 

Special Tests 

  None. 

Differential Diagnoses 

1- The urethral stricture: It shows symptoms of obstructive voiding, Urinary Tract Infection, and retention of the urine ( Zhao, 2016) . It is challenging to determine the adequate drainage of the bladder, thus resulting in inflammation, ischemia, and trauma. The outcomes of the physical examination ruled out the condition. 

2- Overactive bladder: This is the sudden urge to urinate, which is often featured by urinary insistence, and is connected with the inconsistency of urinating. According to Corcos, MacDiarmid, & Heesakkers (2015), the condition is related to frequent and Nocturia in the absence of metabolic diseases. 

3- Acute bacterial Prostatitis; the inflammation of the prostate gland cells caused by infection ( Deem,, 2017) . Usually, the condition appears as severe Urinary Tract Infection (UTI), and it is linked to aspects like obstruction of the bladder outlet to BPH. 

Diagnosis 

Testicular torsion (N44.00) 

The following Differential Diagnoses with ICD 10 codes were considered, but ruled out)` 

1- N32.89 Other specified disorder of bladder 

2- N32 other disease of bladder 

3-N32.9 Bladder disorder, which is unspecified 

Plan/Therapeutics 

Dx tissue culture needs to be performed currently 

Therapeutic : Pharmacological 

Administer Ditropan XL (oxybutynin) to reduce urgency and frequency of urination after being sent for a test on a urine culture to verify the resolution of the infection. In addition, there is a need to return for a basis. In the future is the patient happens to feel the same issue; a prescription of Flomax will remain administered again. 

Plan:  

Conducting more tests 

Giving medication 

Providing Education 

Offering non-medication treatments 

  Evaluation of patient encounter 

Having interacted with the patient for two and a half hours in the previous visit, the 40-year-old male patient has an issue with urination urgency. The problem has compelled him to develop a sign of restlessness. On closer examination and discussion with the patient, it was realized that the frustration resulting from the issue might influence his ability to cope with the possibility of a chronic medical condition. 

A few strengths were identified by the patient. For instance, he is able to practice drinking water and foods that initiate urination continuously. Additionally, the patient has embraced physical exercises and nutrition as self-medication and therapy to fight the issue. 

From the assessment and examination of the patient, he is suffering from Benign Prostatic Hyperplasia. The condition is a histologic illness that is characterized by the proliferation of the prostate cells ( Jakse et al., 2012) . It is the benign growth of the Prostate that starts in the periurethral and transition zones. Additionally, the disease is not cancerous, transmitted sexually, or contagious. When the Prostate glands expand, they squeeze the urethra or the contraction of the urethra muscles leading to increased urination urge, difficulties in urinating, and increased frequency of urinating. BPH causes chronic bladder outlet obstruction, which results in recurrent UTI, urinary retention, renal insufficiency, bladder calculi, and hematuria. The symptoms depicted by A.M are supportive of the diagnosis.