Mr. E is a pleasant, 70-year-old, black, male
Source: Self, reliable source
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.
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
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
<1.1 mg/dL Alkaline Phosphatase 94 26-137 U/L AST 25 0-37 U/L ALT 55 15-65 U/L Pts 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. dont 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).
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