Week 5: NR601 Case Presentation Summary
Patient Information
Mr. K., 70 y/o, Male, Native American.
CC: Nocturia and urinary frequency.
HPI:
Mr. K. is a 70-year-old Native American male who presents with
complaints of nocturia. He indicates that he has been waking up
to urinate more than 3 times each night. In addition, he reports
having urinary frequency during the day, starting and stopping a
stream, and doesn't feel like his bladder is completely empty after
urination. He denies any pain on urination, fever or chills. His last
PSA 2 years ago was negative.
S.
Onset: Not reported
Location: Genitourinary
Duration: Constant. He has this urinary symptoms day and night
time.
Characteristics: He has been up more than 3 times each night
Aggravating Factors: reports he has urinary frequency in the
daytime, starting and stopping a stream, feels he is not emptying
the bladder after each use.
Relieving Factors: None reported
Treatment: None reported
Current medications:
Ibuprofen OTC as needed for joint pain.
,ALLERGIES: NKDA
PMH: Arthritis in both knees.
Social history: non-smoker; drinks 2-3 beers on the weekend
Diagnostics Test: Last PSA was 2 years ago.
ROS
GENERAL CONSTITUTION: No fever, chills or fatigue.
HEENT: Unremarkable
SKIN: Dry and intact
CARDIOVASCULAR: No CP/SOB, palpitations or edema
RESPIRATORY: Denies sob, wheezing, cough or bloody sputum
GASTROINTESTINAL: No complaints reported
GENITOURINARY: Reports of nocturia that has been waking him up
to urinate more than 3 times each night. He is also having urinary
frequency during the day, starting and stopping stream, felling
like his bladder is not emptying completely after urination.
NEUROLOGICAL: No complaints reported
MUSCULOSKELETAL: Patient has hx of arthritis in both knees
HEMATOLOGIC: LYMPHATICS: No lymphadenopathy reported
PSYCHIATRIC: Denies feeling depressed or anxiety
ENDOCRINE: Denies signs and symptoms of hypo or
hyperglycemia
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O
General: no distress; no weakness or fatigue
, Vital signs: blood pressure 140/80, heart rate 76, respirations 16,
temperature 98.0; Weight 210 pounds; height 5'9. His BMI is 31.
Mr. K. is considered obese.
HEENT: unremarkable
Heart: S1 and S2 RRR; no murmurs, gallops or rubs
Lungs: breath sounds clear throughout lung fields
Abdomen: soft, non-tender with positive bowel sounds all 4
quadrants
GU: negative CVA tenderness
Rectal: digital rectal exam reveals enlarged prostate that is
smooth and non-tender.
Diagnostics Test: Last PSA was 2 years ago.
A
Primary Diagnosis:
Benign Prostatic Hyperplasia (BPH) (N40.1): refers to the
proliferation of smooth muscle and epithelial cells within the
prostatic transition zone (American Urological Association, 2012).
The prevalence of benign prostatic hyperplasia (BPH) increases
with age. It is estimated to be approximately 20% for men in their
40s, up to 75% for men in their 50s, and up to 80% for men in
their 70s and 80s (Egan, 2016). BPH can present as lower urinary
tract symptoms such as incomplete emptying (sensation of
incomplete bladder emptying), frequency, intermittency, urgency,
weak stream, straining, or nocturia (Pearson, & Williams, 2014).
Mr. K c/o of nocturia, urinary frequency (urinate more than 3 times
each night) and voiding symptoms such as feeling of incomplete
Patient Information
Mr. K., 70 y/o, Male, Native American.
CC: Nocturia and urinary frequency.
HPI:
Mr. K. is a 70-year-old Native American male who presents with
complaints of nocturia. He indicates that he has been waking up
to urinate more than 3 times each night. In addition, he reports
having urinary frequency during the day, starting and stopping a
stream, and doesn't feel like his bladder is completely empty after
urination. He denies any pain on urination, fever or chills. His last
PSA 2 years ago was negative.
S.
Onset: Not reported
Location: Genitourinary
Duration: Constant. He has this urinary symptoms day and night
time.
Characteristics: He has been up more than 3 times each night
Aggravating Factors: reports he has urinary frequency in the
daytime, starting and stopping a stream, feels he is not emptying
the bladder after each use.
Relieving Factors: None reported
Treatment: None reported
Current medications:
Ibuprofen OTC as needed for joint pain.
,ALLERGIES: NKDA
PMH: Arthritis in both knees.
Social history: non-smoker; drinks 2-3 beers on the weekend
Diagnostics Test: Last PSA was 2 years ago.
ROS
GENERAL CONSTITUTION: No fever, chills or fatigue.
HEENT: Unremarkable
SKIN: Dry and intact
CARDIOVASCULAR: No CP/SOB, palpitations or edema
RESPIRATORY: Denies sob, wheezing, cough or bloody sputum
GASTROINTESTINAL: No complaints reported
GENITOURINARY: Reports of nocturia that has been waking him up
to urinate more than 3 times each night. He is also having urinary
frequency during the day, starting and stopping stream, felling
like his bladder is not emptying completely after urination.
NEUROLOGICAL: No complaints reported
MUSCULOSKELETAL: Patient has hx of arthritis in both knees
HEMATOLOGIC: LYMPHATICS: No lymphadenopathy reported
PSYCHIATRIC: Denies feeling depressed or anxiety
ENDOCRINE: Denies signs and symptoms of hypo or
hyperglycemia
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O
General: no distress; no weakness or fatigue
, Vital signs: blood pressure 140/80, heart rate 76, respirations 16,
temperature 98.0; Weight 210 pounds; height 5'9. His BMI is 31.
Mr. K. is considered obese.
HEENT: unremarkable
Heart: S1 and S2 RRR; no murmurs, gallops or rubs
Lungs: breath sounds clear throughout lung fields
Abdomen: soft, non-tender with positive bowel sounds all 4
quadrants
GU: negative CVA tenderness
Rectal: digital rectal exam reveals enlarged prostate that is
smooth and non-tender.
Diagnostics Test: Last PSA was 2 years ago.
A
Primary Diagnosis:
Benign Prostatic Hyperplasia (BPH) (N40.1): refers to the
proliferation of smooth muscle and epithelial cells within the
prostatic transition zone (American Urological Association, 2012).
The prevalence of benign prostatic hyperplasia (BPH) increases
with age. It is estimated to be approximately 20% for men in their
40s, up to 75% for men in their 50s, and up to 80% for men in
their 70s and 80s (Egan, 2016). BPH can present as lower urinary
tract symptoms such as incomplete emptying (sensation of
incomplete bladder emptying), frequency, intermittency, urgency,
weak stream, straining, or nocturia (Pearson, & Williams, 2014).
Mr. K c/o of nocturia, urinary frequency (urinate more than 3 times
each night) and voiding symptoms such as feeling of incomplete
