Identifying Data: 

Full Name: Mr. PC

Address: St. Albans, NY

Date of Birth: XX/XX/1951

Date & Time: 09/11/24 10AM

Location: St Albans, NY

Religion: Christian 

Source of Information: Self

Reliability: Reliable 

Source of Referral: Self 

 

Chief Complaint: “I’m peeing a lot” x 2 weeks

History of Present Illness: 

Resident is a 73 year old veteran, domiciled in private apartment, college educated, retired, with past psychiatric history of schizoaffective disorder (bipolar type), and PMHx of HTN, HLD, A.fib, hypothyroidism, venous stasis, OA, morbid obesity s/p bariatric surgery.

He complains of increased urinary frequency, which has been progressively worsening over the past 2 weeks. He reports needing to urinate approximately 5 times during the day and waking up 2 times per night. He describes the urge to urinate as sudden and difficult to postpone, often resulting in incomplete bladder emptying. Resident has noticed a weak urinary stream and intermittent stopping and starting when urinating. He has not tried any OTC medications for his symptoms. However, he expresses he is frustrated with the impact of these urinary issues on his daily activities and sleep. He denies dysuria, hematuria, or any changes in the color and odor of his urine. Denies fever, chills, and flank pain. Denies recent UTIs or history of STIs.

Geriatric Assessment: 

• ADLs and IADLs: needs assistance with some ADLs
• Decision Capacity: NOK involved in decision making 
• Health care proxy: A.C (brother)
• Visual Impairment – No
• Hearing impairment – No
• Falls in the past year – No
• Assistive devices used – wheelchair
• Osteoporosis: No
• Depression: No
• Nutrition and Diet: Fair
• Urinary/Fecal Incontinence: No
• Bowel and Bladder function: Fair
• Sleep: Poor 
• Pain: No
• Cognitive Impairment: No (MMSE: 26)
• Home safety issues: none, lives at the VA in St. Albans for long term care
• Advanced directives: UTD and on file 
• Elder abuse: no evidence present

Past Medical History: 

• Schizoaffective disorder (bipolar type)
• HTN
• HLD
• Atrial fibrillation
• Hypothyroidism
• Venous stasis
• Osteoarthritis
• Morbid obesity s/p bariatric surgery

Immunizations: Fully up to date

Childhood illnesses: non-contributory

 

Past Hospitalizations: 

Did not recall

 

Past Surgical History:  

Bariatric Surgery (unable to specify month/year) 

 

Medications: 

• Acetaminophen 1000 mg PO Q8H
• Apixaban 5 mg PO Q12H
• Aripiprazole 20 mg PO daily
• Atorvastatin 80 mg PO daily
• Levothyroxine 50 mcg PO daily
• Metoprolol 25 mg PO daily
• Mirtazapine 15 mg PO Qhs, 7.5 mg PO daily PRN
• Quetiapine 25 mg PO Q12h, 100 mg PO Qhs
• Lisinopril 10 mg PO daily

 

Allergies: 

No known drug/food allergies

 

Family History: 

Non-contributory

 

Social History: 

Mr. PC is a male living in the VA community living home. He is an army veteran from the Vietnam era. 

Habits: Denies smoking. Denies smoking marijuana recreationally. Denies alcohol intake. Denies illicit drug use. 

Travel: Denies recent travel.  

Diet: States his diet is managed by a nutritionist. 

Exercise: States he works with a PT/OT 3x/week 

Sexual history: Denies being currently sexually active. Denies history of STIs.

 

Review of Systems:

General – Denies weight loss, fever, malaise, weight change, or night sweats.

Skin, hair, nails – Denies pain, pruritus, discoloration, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting.

Eyes – Denies discharge, eye pain, visual changes, and photophobia. Last eye exam: 6 months ago.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Next dental exam 09/16/24

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema

Gastrointestinal System – Denies heartburn/regurgitation. Denies abdominal pain, diarrhea, vomiting, loss of appetite, hemorrhoids, constipation, rectal bleeding. 

Genitourinary System – Endorses nocturia, increased frequency, urinary hesitancy. Denies flank pain, oliguria, urgency, incontinence.

Sexual History – Denies being currently sexually active. Denies history of STIs. 

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies stiffness, erythema, joint pain. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies lymph node enlargement, blood transfusions, clotting.

Endocrine system – Denies heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed male, appearing as his stated age of 73 years, with large build. He appears awake, alert, oriented to person and place. He is cooperative and pleasant.

Vital Signs: 

BP: Seated – (R) 116/70

R: 16 breaths/min, unlabored 

P: 60 beats/min, regular rhythm

T: 97.8 (Tympanic)

O2 Sat: 100%, room air 

Height: 5’9 inches     Weight: 272 lbs     

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No visible scarring. 

Hair: No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. 

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies. 

 

Mouth/Neck/Pharynx

Lips: Pink, moist, no cyanosis or edema. 

Buccal Mucosa: Pink, well hydrated, no masses, ulcerations, or leukoplakia.

Palate: Pink, well hydrated, no scars or ulcerations present.

Teeth: Dentition fair, no plaque buildup.

Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration. 

Tongue: Pink, well papillated. Symmetrical with normal texture. 

Oropharynx: Well hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations. 

Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation.

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. No tenderness to palpation.

 

Heart

Regular rate and rhythm. S1/S2 with no murmurs, splitting, friction rubs.

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is soft, symmetrical, and nondistended. No ecchymosis, rebound, or guarding. No suprapubic tenderness or CVA tenderness. 

Neuro Exam 

Mental Status: A&O x2, cooperative, thoughts & speech coherent.

 

GU

No lesions or abnormal discharge on penis. Testes are descended, smooth, and without swelling or tenderness. No lumps or hernias. (DRE done by preceptor) Prostate enlarged and smooth. Median sulcus is less distinct. 

 

Differential Diagnosis

• BPH

• UTI

• Urethral Stricture

 

Assessment

A 73 year old male with significant past medical history complaining of urinary frequency, nocturia, and hesitancy. On physical exam, the prostate is enlarged and smooth and the median sulcus is less distinct. Patient is currently afebrile and non-toxic. 

 

Lab Results:

• Urinalysis
  • Urine color: Yellow
  • Appearance: Clear
  • Urine pH: 6
  • Urine specific gravity: 1.017
  • Urobilinogen: Neg
  • Urine blood: Neg
  • Urine bilirubin: Neg
  • Urine ketones: Neg
  • Urine glucose: Neg
  • Urine protein: Neg
  • Nitrite, urine: Neg
  • Leu est: Neg
  • Microscopic: Not indicated
• PSA → 0.42 
• HbA1c → 5.4% 

 

Plan

• Labs/Imaging:
  • Urinalysis to rule out UTI.
  • PSA level to screen for prostate cancer.
  • HbA1c to assess if high blood sugar levels are leading to increased urinary frequency. 
• Obtain bladder US to assess for post-void residual. 
• Lifestyle modifications: monitor fluid intake, avoid drinking after 5pm. Maintain blood sugar control. 
• Initiate Tamsulosin 0.4 mg PO daily + Finasteride 5 mg PO daily for BPH. 
• Urology consult as needed.