Mr. E is a pleasant, 70-year-old, black, male
Source: Self, reliable source
Subjective:
Chief complaint: “I urinate frequently.”
HPI: Patient states that he has had an increase in urination for the past several years, which seems to be worsening over the past year. He estimates that he urinates clear/light yellow urine approximately every 1.5-2 hours while awake and is up 2-4 times at night to urinate. He states some urgency and hesitancy with urination and feeling of incomplete voiding. He denies any pain or blood. Denies any head trauma. Denies any increase in thirst or hunger. He denies any unintentional weight loss.
Allergies: NKA
Current Mediations:
Multivitamin, daily
Aspirin, 81 mg, daily
Olmesartan, 20 mg daily
Atorvastatin, 10 mg daily
Diphenhydramine, 50 mg, at night
Pertinent History: Hypertension, hyperlipidemia, insomnia
Health Maintenance. Immunizations: Immunizations up to date
Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members
Social History: Patient lives alone. He drinks one cup of caffeinated coffee each morning at the local diner. He denies any nicotine, alcohol or drug use.
ROS: Incorporated into HPI
Objective:
VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 195 lbs, height: 70 inches.
Mr. E is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age.
Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Respiratory: Clear to auscultation
Abdomen: Bowel sounds positive. Soft, nontender, nondistended, no hepatomegaly
Neuro: CN 2-12 intact
Renal/prostate: Prostate enlarged, non-tender. No asymmetry or nodules palpated
Labs:
Test Name
Result
Units
Reference Range
Color
Yellow
Yellow
Clarity
Clear
Clear
Bilirubin
Negative
Negative
Specific Gravity
1.011
1.003-1.030
Blood
Negative
Negative
pH
7.5
4.5-8.0
Nitrite
Negative
Negative
Leukocyte esterase
Negative
Negative
Glucose
Negative
mg/dL
Negative
Ketones
Negative
mg/dL
Negative
Protein
Negative
mg/dL
Negative
WBC
Negative
/hpf
Negative
RBC
Negative
/hpf
Negative
Lab
Pt’s Result
Range
Units
Sodium
137
136-145
mmol/L
Potassium
4.7
3.5-5.1
mmol/L
Chloride
102
98-107
mmol/L
CO2
30
21-32
mmol/L
Glucose
92
70-99
mg/dL
BUN
7
6-25
mg/dL
Creat
1.6
.8-1.3
mg/dL
GFR
50
>60
Calcium
9.6
8.2-10.2
mg/dL
Total Protein
8.0
6.4-8.2
g/dL
Albumin
4.5
3.2-4.7
g/dL
Bilirubin
1.1
<1.1
mg/dL
Alkaline Phosphatase
94
26-137
U/L
AST
25
0-37
U/L
ALT
55
15-65
U/L
Pt’s results
Normal Range
Units
WBC
9.9
3.4 – 10.8
x10E3/uL
RBC
4.0
3.77 – 5.28
x10E6/uL
Hemoglobin
11.5
11.1 – 15.9
g/dL
Hematocrit
35.0
34.0 – 46.6
%
MCV
85
79 – 97
FL
MCH
28
26.6 – 33.0
Pg
MCHC
34
31.5 – 35.7
g/dL
RDW
14
12.3 – 15.4
%
Platelets
220
150 – 379
X10E3/uL
PSA
5.4
0-4.0
ng/mL
Assessment:
Diagnosis: Benign prostatic hyperplasia, ICD-10: N40.1
Please answer the following:
For the sake of this case study, the patient has confirmed BPH and prostate cancer has already been ruled out. Hence, please document your prescribed treatment plan for this patient (i.e. don’t state “refer to urology”).
- What is your treatment plan (include specific dosage and frequency)? Why did you choose this treatment plan? Do you change any of his current medications? In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your decision. Does the patient have any comorbidities that influenced your choice as well (1 point)?
Three months later, the patient notes improvement, but no resolution of symptoms. What would be your next prescribed treatment option (1 point)?
- Document the education you would provide for this patient, specific to the prescribed medication. Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).