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Case 1 Chief Complaint (CC)

September 25, 2024

	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 present dysuria and nocturia.
PMH	Benning 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
Card	S1S2 without rub or gallop S4 present
Abd	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

Once you received your case number, answer the following questions:

1.
What other subjective data would you obtain?

2.
What other objective findings would you look for?

3.
What diagnostic exams do you want to order?

4.
Name 3 differential diagnoses based on this patient presenting symptoms?

5.
Give rationales for your each differential diagnosis.

6.
What teachings will you provide?

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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