NR 603 Week 5 APEA Predictor Assignment Part 2
TB is a 50-year-old Caucasian male that presents to the primary care office with the chief complaint of dysuria, urinary frequency, inability to completely empty his bladde
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NR 603 Week 5 APEA Predictor Assignment Part 2
TB is a 50-year-old Caucasian male that presents to the primary care office with the chief complaint of dysuria, urinary frequency, inability to completely empty his bladder, post void dribbling, perineal pain, and pain at the tip of the penis.”
Subjective:
Demographics: TB is a lifelong resident of the Greenville area. He is entrepreneur and owns several local businesses in the area.
PMHx: (E29.1) Testicular hypofunction , (N52.9) Erectile dysfunction, Immunizations are up to date, No history of sexually transmitted diseases. Childhood diseases include chicken pox age 5.
Medications: Testosterone cypionate 100mg IM Q 2 weeks, Viagra 50 mg 1 PO prn, Vitamin D, Omega 3,
PSHx: None
Allergies: NKDA
FamilyHx: Father: T1DM, CAD, HTN
Mother: Parkinson’s, HTN, Atrial fibrillation
MGM: Breast Cancer deceased age 78
MGF: SCD at age 48
PGM: HTN, T2DM, CAD, CHF deceased age 79
PGF: HTN, CHF deceased age 89
Lifestyle: Married for 30 years in a monogamous relationship. Sexually active but states “it could be more often, sometimes it is only once in 2 weeks but then might be twice in one day.” Admits to rare but recent unprotected anal intercourse with spouse Three grown sons all out of the home. Exercises daily alternating strength training and aerobic exercise, Never smoked, Consumes 2 alcoholic beverages nightly 4 times a week, No illicit substance abuse, Diet consists of mostly a plant based diet with chicken 3 times a week and occasional red meat once a month.
HPI: “For the past week I have been experiencing urinary frequency that is accompanied by a burning sensation in my urethra. I have to sit to void, and it takes a long time to feel as if I have completely emptied my bladder. Then I notice a little dribbling of urine several minutes after getting up. I also have scrotal heaviness, pain in the perineal area, and at the tip of the penis. I have tried drinking more water to flush out my system and have taken some of my wife’s
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