,Patient Information
Age: 52 years old
Gender: Male
Reason for Encounter: Peeing problem
Setting: Primary care clinic
History of Present Illness (HPI)
A 52-year-old male presents to the primary care clinic complaining of
urinary difficulties for the past 6 months. He describes a constellation
of symptoms, including a weak urinary stream, hesitancy (difficulty
starting urination), and a sensation of incomplete bladder emptying
after voiding. Additionally, he reports increased urinary frequency
(voiding 6–8 times during the day, compared to his baseline of 4–5
times) and nocturia (waking 2–3 times per night to urinate, previously
none). These symptoms have progressively worsened, causing
significant disruption to his sleep and daily activities, particularly at his
job as a delivery driver, where frequent restroom breaks are
inconvenient. The patient notes mild lower abdominal discomfort,
described as a dull pressure, but denies dysuria, hematuria, urgency, or
, incontinence. He has not experienced fever, chills, weight loss, or other
systemic symptoms. The patient attributes some symptoms to his long
hours of sitting during work but cannot identify a specific trigger for
onset.
Onset: Gradual, starting 6 months ago, with slow progression.
Location: Lower urinary tract (bladder and urethra).
Duration: Persistent, occurring daily, with worsening severity.
Characteristics: Weak stream, hesitancy, incomplete bladder
emptying, increased frequency, nocturia.
Aggravating Factors: Prolonged sitting (work-related); no other
specific triggers noted.
Relieving Factors: None reported; symptoms persist despite
attempts to void fully.
Associated Symptoms: Mild suprapubic discomfort; no flank pain,
fever, or neurological symptoms.
Severity: Moderate, significantly impacting sleep (due to nocturia)
and work (due to frequency).
Relevant History:
Age: 52 years old
Gender: Male
Reason for Encounter: Peeing problem
Setting: Primary care clinic
History of Present Illness (HPI)
A 52-year-old male presents to the primary care clinic complaining of
urinary difficulties for the past 6 months. He describes a constellation
of symptoms, including a weak urinary stream, hesitancy (difficulty
starting urination), and a sensation of incomplete bladder emptying
after voiding. Additionally, he reports increased urinary frequency
(voiding 6–8 times during the day, compared to his baseline of 4–5
times) and nocturia (waking 2–3 times per night to urinate, previously
none). These symptoms have progressively worsened, causing
significant disruption to his sleep and daily activities, particularly at his
job as a delivery driver, where frequent restroom breaks are
inconvenient. The patient notes mild lower abdominal discomfort,
described as a dull pressure, but denies dysuria, hematuria, urgency, or
, incontinence. He has not experienced fever, chills, weight loss, or other
systemic symptoms. The patient attributes some symptoms to his long
hours of sitting during work but cannot identify a specific trigger for
onset.
Onset: Gradual, starting 6 months ago, with slow progression.
Location: Lower urinary tract (bladder and urethra).
Duration: Persistent, occurring daily, with worsening severity.
Characteristics: Weak stream, hesitancy, incomplete bladder
emptying, increased frequency, nocturia.
Aggravating Factors: Prolonged sitting (work-related); no other
specific triggers noted.
Relieving Factors: None reported; symptoms persist despite
attempts to void fully.
Associated Symptoms: Mild suprapubic discomfort; no flank pain,
fever, or neurological symptoms.
Severity: Moderate, significantly impacting sleep (due to nocturia)
and work (due to frequency).
Relevant History:
