, 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 reporting urinary
difficulties for the past 6 months. He describes a weak urinary stream,
hesitancy (difficulty initiating urination), and a sensation of incomplete
bladder emptying. He also reports increased urinary frequency (voiding
6–8 times daily, compared to his usual 4–5 times) and nocturia (waking
2–3 times nightly to urinate). The patient denies dysuria, hematuria, or
urinary incontinence. He reports mild discomfort in the lower abdomen
but no significant pelvic or flank pain. The symptoms have progressively
worsened, impacting his quality of life, particularly due to interrupted
sleep and frequent restroom visits during work as a delivery driver. He
denies recent trauma, urinary tract infections (UTIs), or changes in
bowel habits.
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 reporting urinary
difficulties for the past 6 months. He describes a weak urinary stream,
hesitancy (difficulty initiating urination), and a sensation of incomplete
bladder emptying. He also reports increased urinary frequency (voiding
6–8 times daily, compared to his usual 4–5 times) and nocturia (waking
2–3 times nightly to urinate). The patient denies dysuria, hematuria, or
urinary incontinence. He reports mild discomfort in the lower abdomen
but no significant pelvic or flank pain. The symptoms have progressively
worsened, impacting his quality of life, particularly due to interrupted
sleep and frequent restroom visits during work as a delivery driver. He
denies recent trauma, urinary tract infections (UTIs), or changes in
bowel habits.
