Description
Mr. E.D. is a 63-year-old retired mail carrier who presents to his primary care provider for a routine follow up for his hypertension. He complains of a 4-day history of dysuria, increased urinary frequency, and nocturia. He states that he has been having fever and chills. Denies any recent sexual activity. On examination, his temperature is 99.5 F., pulse 75 and regular, respiratory rate 16 and unlabored, and blood pressure 135/85. He does not appear acutely ill and is in no apparent distress. Examination of the abdomen was normal. A digital rectal exam revealed a moderately enlarged, firm, non-tender prostate gland. He states that he has severe urgency and difficulty urinating.
- What are some appropriate questions to ask the patient?
- What are three differential diagnoses for the patient?
- What physical examination would you perform?
- What diagnostics would you include?
- Create an evidenced-based plan of care. Include pharmacological and non-pharmacological treatments.
Explanation & Answer
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Running head: PATIENT CASE DISCUSSION
Patient Case Discussion
Student’s Name
Institutional Affiliation
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PATIENT CASE DISCUSSION
2
Patient Case Discussion
The Questions to Ask the Patient
I will ask MR. E.D several questions to understand the contributory factors to various
illnesses that he may have. The questions will help me identify the test that I should perform.
The queries will also aid me to obtain information about the medications the patient take, which
is essential during treatment to avoid drug interaction.
The following is a list of the questions I will ask Mr. E.D
1. Do you have any health condition or complication other than hypertension?
2. What prescribed and over the counter medications are you taking?
3.
Does anyone in your family have or had cancer particularly prostate cancer
4. Do you urinate more frequently than normal? Approximately how much time do you get up
pee at night?
5.
Do you express difficulties urinating like having to press urine to empty your bladder?
6. Do you have trouble controlling your bladder
7.
Does your urine or semen contain blood
8. How is the velocity of your urine stream?
9. How frequently do you have sexual intercourse?
10. Do you have a problem getting er...
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