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Download COMPREHENSIVE CASE 62 YEARS iHuman case study- Im peeing all the time- dissecting Urinary and more Exams Advanced Education in PDF only on Docsity!
COMPREHENSIVE CASE 62 YEAR OLD (reason for Encounter: I’m peeing all the time, location) OUTPATIENT CLINIC WITH ACCESS TO X — RAY, ECG AND LABORATORY CAPABILITIES Case Instructions H&P+Dx CASE PLAY SETUP AND INSTRUCTIONS a aa bi _ a ee 62 yfo the cme 6 1° (185 an) Reason for encounter fm peeing al the time ATTEMPTS AVAKABLE: Location Outpationt clinic with x-ray, ECG, and © You are permed 1 attempt for this assignment. laboratory capabilities Patient Information: * Name: 62-Year-Old Male * Height: 6'1" (185 cm) « Reason for Encounter: Frequent urination — "I'm peeing all the time.” © Location: Outpatient clinic with x-ray, ECG, and laboratory capabilities Reason for Encounter: The patient presents with complaints of frequent urination, a common issue for older males. This condition can often be attributed to various underlying causes, including benign prostatic hyperplasia (BPH), overactive bladder (OAB), diabetes, or urinary tract infections (UTI). The focus will be on identifying the primary cause of this symptom, followed by appropriate treatment. History of Present Ilness (HPI): * Chief Complaint: Frequent urination, occurring both during the day and night. ¢ Symptoms: Increased frequency of urination, urgency, possible nocturia (waking up during the night to urinate), no significant pain or burning during urination. « Onset: Symptoms began gradually over the past several months. « Exacerbating Factors: Drinking large amounts of fluids, especially caffeinated beverages. ¢ Relieving Factors: Reducing fluid intake and urinating more frequently during the day. « Associated Symptoms: No significant pain, fever, or hematuria (blood in the urine). Peeing All the Time’ in a 62-Year-Old ~ Week #10 iHuman Case Study & Outpatient Clinic Analysis (Class 6550)" FIND ALL THE SCREENSHOTS IN THIS DOCUMENT! ALL ACTUAL SCREENSHOTS FOR THE ASSESSMENT THE SCREENSHOTS INCLUDES ALL SECTIONS SUCH AS HPI, PHYSICAL EXAMINATION, DIAGNOSIS, TREATMENT AND MANAGEMENT PLAN COMPREHENSIVE CASE 62 YEARS iHuman case study: Im peeing all the time- dissecting Urinary frequency in a 62- year - old Male, Week 10 COMPREHENSIVE CASE 62 YEARS iHuman case study: Im peeing all the time- dissecting Urinary frequency in a 62- year - old Male, Week 10 Case Section Physical exams Key findings organization Problem Statement Differentials fone: | =e 20min 6 Time spent Status | Performance Details 28min 63 questionsasked, 12 37sec to the case'slist Done ee SSsec items in the 43sec missed relative to correct, 2 listed case's DDx, the wa i fad! ex peg te ae correct, 6 misse S2sec 9 Tis a on Dwi Done | 33sec finding listed; 15 by was 2 case's list missed relative 2 the case's the case 89 words correct, 2 ‘< - = Differentials Done S4sec ranking 100% Report generated on 1/5/2025; COMPREHENSIVE CASE 62 YEARS iHuman case study: Im peeing all the time- dissecting Urinary frequency in a 62- year - old Male, Week 10 - | How can | | help you? | symptoms? [ | [ Onset/events | Any other | | | | TOP SELLER : UrO| od Ferritin Blood TIBC, blood CMP, blood ECG 12 lead TSH-blood Troponin I blood XRay AP/Lat Problem Statement by Lester Trastoy COMPREHENSIVE CASE 62 YEARS iHuman case study: Im peeing all the time- dissecting Urinary frequency in a 62- year - old Male, Week 10 Category Data entered by Lester Trastoy Reason for Encounter History of present illness Case: Management Pian Pharmacologic care: = Give ferric citrate 1 g (210 mg ferric iron) PO daily. + Discontinue ibuprofen due to the risk of bleeding. Start acetaminophen 500 mg 1 tab PO q 4-6 hrs prn headache. Supportive care: - Rest, hydrate. Patient education: - Provided education on the diagnosis and need for additional testing and follow-up with PCP. + Provided education on treatment medication, G! side effects, and dark stools. Advised to take with orange juice and food. Do not take with antacids. Call if side effects are too troublesome before getting in to see PCP. Follow-up: * Follow-up with PCP for treatment monitoring and referrals. Recommend the following with PCP: © Repeat CBC and iron studies in 8 weeks. e Refer to Gi for colonoscopy and consider upper Gi scope, though NSAID use is minimal. © Pursue pelvic ultrasound to look for non- perimenopausal causes of bleeding. - Follow-up in ER if fatigue, dyspnea, lightheadedness, or bleeding worsens or if she experiences chest pain or syncope. Electronic Health _ Record by Lester Trastoy on case Ava la Pilar @ Human patients by KAPLAN) History of Present Illness Past Medical History Category Data _ entered by Lester Trastoy COMPREHENSIVE CASE 62 YEARS iHuman case study: Im peeing all the time- dissecting Urinary frequency in a 62- year - old Male, Week 10 Psychiatric Lymphatic What treatments have you had for your headache? | just take some ibuprofen when | get one Does your headache come and go? Yes,. | don’t have one right now. How severe (1-10) is your headache? I'd say mild Where more precisely is the pain in your head? Kind of all over. Just garden variety headache Does the pain in your head radiate someplace else? Where? | don’t have a headache now but when | have one, it stays in one place. How long do your periods last? | have heavy bleeding for 2-3 days, but the total duration is usually around 7-8 days. How many tampons ar pads do yau use daily? | use doth simultaneously; | double up using both tampons and pads for the rst 2-3 days and | change my tampon every two to four hours. Now that I think about it, it is heavier than it was a couple of years ego. When did your last period begin? About 4 weeks ago When did your abnormal vaginal bleeding start? It’s been a little heavier for about 10 months or a year Do you have any pain in your chest? No Any changes in the frequency of your bowel movements? | have loose stools occasionally and have been having them over the past year or so. Otherwise, nothing new. How often do you have headaches like this? iHuman does not have this question anymore How often do you feel lightheaded? iHuman does not have this question anymore How much of your medication did you take? Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetitie? iHuman does not have this question anymore, so | broke it up to get the answers | needed. See the next four questions. Do you have trouble with hot or cold temperatures? No, | don’t think so. Any changes in your thirst? No increased thirst, urination or appetite. All good. How is your appetite? Any recent change? Oh, my appetite is ne. Always is. Has there been a change in your urination frequency? No Do you have night sweats? No Do you bruise or bleed easily? Nope Tell me about your work? I’m a radiology tech. | work in private practice Do you now or have you ever smoked or chewed tobacco? Never Are your immunizations up to date? Yes, they are Have you ever had a Pap smear? Yes. | stay on top of that and they are always normal. Over the last two weeks, how often have you been bothered by feeling down, depressed, or hopeless? Don't have that problem Have you ever been hospitalized? Just for the deliveries of my kids Is there any blood in your stools or with your bawel movements? Nope. Do you have pain/discomfort when you urinate? Nope Have you been having fevers? No Do you have chills? No Do you have any skin problems? iHuman does not have this question anymore Do you have any breast issues? iHuman does not have this question anymore Do you have joint ar bone pain? Nope Do you have any nausea or vomiting? No Do you have unusual heartbeats (palpitations)? No, I haven’t PHM,FH,SH Questions Can you tell me about any current or past medical problems you have had? | have been lucky and very healthy. No heart disease, blood problems, or anything else like that. Are you taking any prescription medications? None et all Are you taking any OTC or herbal medications? Occasionally | take ibuprofen if | get a cold and have a fever but that hasn’t been my problem recently. My headaches are the reason that I've been taking ibuprofen now. Are you now or have you ever been anemic? iHuman does not have this question anymore Do you have allergies? Not that I'm aware of Can you tell me about yaur diet? What do you normally eat? | turned vegan about 2 years ago. | think it will help me keep my weight under control. Do you drink alcohol? If so, what do you drink and how many drinks per day?! drink a glass of wine with dinner pretty much every day. HP! Statement AP is a 50 y/o female who presents with several months of fatigue and lightheadedness, shortness of breath, and headaches. Shortness of breath has been going on for several months. Worse with activity and better with rest. Fatigue for several months impacting her quality of life. Better with rest. Worse with activity. Denies resolution after a good night's rest. She reports dizziness when changing positions. Syncope this morning with activity. Headaches that come and go. Aching and Mild in nature. Worse with activity. Better after taking Ibuprofen. In addition, she reports heavy menstrual periods for a year. LMP 4 weeks ago, lasting 7-8 days with 2-3 of heavy bleeding and having to change her tampon and pad every 2-4 hours. She reports taking OTC Ibuprofen for her headaches. Denies di*culty swallowing, pain radiating elsewhere, or chest pain. Do you have any skin itching or burning? No 
