A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow.
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been experiencing this over the past two years, but for the past two weeks, the symptoms
have increased significantly. The current symptoms are similar to what he experienced in the past.
However, for the past two weeks, he has had increased nocturia, with decreased strength of urinary
flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very
troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow
and this is interfering with daily activities. He needs to pass urine four to five times every night. He has
been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work
up in the past, but now the symptoms have been increasing in severity. He believes he had a lowgrade
fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had
significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him
to seek medical help now.
PMH
Patient has not sought any medical care for this problem to date. He is being treated for hypertension
and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five
years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was
treated and then released. There are no recent hospitalizations and no surgeries.
ROS
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in
the stool. No gross hematuria.
MEDICATIONS
Cardizem 240mg daily
Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.
ALLERGIES/REACTIONS
No known drug allergies
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NSG6001 ? Advanced Nursing Practice I
?2015 South University
NSG6001 ? Advanced Nursing Practice I
Week 4: Gastroenterology Clinical Case
SOCIAL HISTORY
Patient has a master?s degree in engineering and his income is $65,000.00 per year. Though
the patient is educated, he lacks an understanding of resources available to him. Patient
has no problems with finances. He has excellent access to healthcare, but most often does
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