differential dx and etc

SOAP Note Week Three: Benign Prostatic Hyperplasia

Student

United States University

FNP592: Common Illnesses Across the Lifespan

Professor

November 21, 2022

SOAP Note Week three:

ID:

Client’s Initials: R.T Age: 74 Race: Asian Gender: Male Date of Birth: November 1, 1948

Marital Status: Married

The patient presents to the clinic accompanied by his son.

Subjective:

CC: "I do urinate frequently especially at night and I am having trouble starting to urinate for 4 weeks now "

HPI:

The 74-year-old Asian male presents to the clinic with complaints of urinary frequency especially at night that started 4 weeks ago. He also reported that he is unable to empty the bladder fully, lost a small amount of urine due to a weak stream, having to push to be able to maintain urination and empty the bladder fully. The patient denies lower back pain, burning sensation during urination or any reproductive system disorder. He also denies fever, vomiting, fatigue, flank pain, nausea or trauma of the urinary system.

Past Medical History:

· Medical problem list: Hypertension, Hyperlipidemia

· Preventative care: Eye exam (01/2022), all immunizations are up to date. He recently received pneumococcal, influenza and covid vaccine.

· Surgeries: None

· Hospitalizations: no history of hospitalization.

Allergies: Has no known allergies

Medications: Amlodipine 10 mg once a day, Atorvastatin 20mg once daily

Family History: history of diabetes and hypertension (father-deceased), and hypertension, hyperlipidemia and diabetes (mother)

Social History: The patient is a retired teacher. He is married and lives with his wife. He quit smoking 2 years ago, no use of illicit drugs but occasionally takes alcohol. He reports he loves to walk in the morning with his wife.

Review of System

Constitutional: Denies fever, chills, fatigue, excessive sweating, or weight changes

Head/Eyes/Ears/Nose/Mouth: Denies trauma to the head, headaches, or dizziness. Denies photophobia, eye pain blurry of vision or eye discharge. denies ear pain, tinnitus or loss of hearing. Denies nasal congestion, rhinorrhea, nose bleeding or mouth sores

Throat: Complaints of sore throat, neck pain, and swallowing pain.

Cardiovascular: Denies reporting chest pain, shortness of breath, palpitations, syncope, or chest pressure or lower leg edema.

Pulmonary: Denies difficulty breathing, cough, wheezing, or chest wall pain with breathing

Genitourinary: reports urinary frequency, dribbling, hesitancy, straining, incomplete bladder emptying but denies incontinence, hematuria or burning sensation during urination

Gastrointestinal: Denies poor appetite, nausea, vomiting, abdominal pain, heartburn, constipation, or diarrhea.

Musculoskeletal: Denies muscle pain, joint stiffness, backpain or joint pain

Neurological: Denies dizziness, headache, seizures, problems, weakness

Endocrine: Denies excessive sweating, polyphagia, cold or heat intolerance or polyuria.

Psychiatric: Denies depression, anxiety, mood swings, memory loss, or insomnia

Hematologic/Lymphatic denies any swellings

Allergic/Immunologic: Denies allergies, denies frequent infections

Objective

Vital Signs: HR-80 BP-129/79 Temp-97.5F RR-18 SpO2-99% Pain- 0 pain

Height-157.5cm Weight -80.45kg BMI – 32.37kg/m2

Physical Exam

General: Well-developed, obese, age appropriate, with normal gait, normal posture, dressed appropriately and is well-kempt. He is awake, alert and oriented x 3.

Vitals reviewed and stable.

Skin

On inspection, his skin color is per his ethnicity, it is intact with no lesions or rashes.

On palpation, the skin is warm well perfused with a normal skin turgor.

HEENT

Head: On inspection, it is normocephalic, atraumatic with no scars and he has

normal hair distribution. On palpation, no tenderness and no masses were palpable. Eye: On

inspection, the sclera and conjunctiva are both clear and his extraocular movements are

normal. On fundoscopy, he has adequate visual acuity and pupils' examination revealed

PERRLA. Ear: The pinna on inspection is normal in shape and on otoscopy examination, the

Tympanic membranes are not bulging and they are clear. Nose: On inspection, the shape is

normal, the nasal turbinates are patent, and nasal mucosa is intact and there was no discharge.

On palpation, there was no tenderness over the sinuses. Throat: On inspection, the mucosa is

moist, pink, with no erythema and the tonsils are not swollen.

Neck: On inspection, it is supple, with no scars or swellings and the range of movement is

normal. On palpation, the trachea has not deviated, no tenderness, and no lymphadenopathy.

Cardiovascular: On inspection, no chest deformity, no engorgement of the jugular vein, and

no edema on the lower extremities. On palpation, all peripheral pulses are palpable and he

has a normal capillary refill time. On auscultation, S1 and S2 were heard with no added

sounds.

Respiratory: On inspection, the chest moves with respiration, no deformity, and no use of

accessory muscles. On palpation, he has a bilaterally equal chest expansion with no

tenderness and present and equal tactile fremitus. On percussion the chest was resonant and

on auscultation, vesicular breath sounds bilateral.

Gastrointestinal: On inspection, the abdomen is flat, moves with respiration, and there are

no scars. On auscultation, normal bowel sounds in all the quadrants, and on percussion, the

The abdomen is tympanic, but the liver and spleen are dull. On palpation, there was no

organomegaly or tenderness.

Genito-Urinary: On inspection, he has scant pubic hairs, and his external genitalia is normal

in shape. On palpation, there was no tenderness on the external genitalia and the suprapubic

region. On digital rectal examination, the prostate is firm, smooth, with a rubbery consistency

and it is enlarged with mild tenderness on palpation.

Peripheral Vascular: On inspection, all his limbs and digits are present, with no scars, no

cyanosis, no pallor, and no tar staining on the fingers. On palpation, he has normal and

bilaterally equal temperature, capillary refill time is normal, and all the pulses were palpable

and his sensations were intact. On auscultation of the carotid artery and the abdominal aorta,

There were no bruits.

Musculoskeletal: On inspection, he has no joint swelling and no deformity noted in all the

limbs. On palpation, there is no tenderness and no swelling of the joints and on movements of

the joints, there was no tenderness, and the range of movement is normal.

Neurological: He is awake, alert, and is oriented ×3, and he was very cooperative during the

assessment. He has an erect posture with a normal gait, normal muscle power, and tone, on

examination of the cranial nerves they were all intact and his sensations were intact. He has

an intact memory and his speech are also normal in tone and volume

Assessment

Differentials

1.

2.

3.

Diagnosis

1.Abnormal PSA…….

Plan

Diagnostics:

Treatment:

Education:

Follow Up:

References

Gunjan Gupta, & Rachel H. McDowell. (2019). Peritonsillar Abscess. https://www.ncbi.nlm.nih.gov/books/NBK519520/

Palm, J., Fuchs, K., Stammer, H., Schumacher-Stimpfl, A., & Milde, J. (2018). Efficacy and safety of a triple active sore throat lozenge in the treatment of patients with acute pharyngitis: Results of a multi-centre, randomised, placebo-controlled, double-blind, parallel-group trial (DoriPha). International Journal of Clinical Practice, 72(12), e13272. https://doi.org/10.1111/ijcp.13272