IHUMAN CASE STUDY 62-YEAR-OLD PATIENT (I'M PEEING ALL THE TIME) FREQUENT URINATION IHUMAN, Exams of Nursing

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| IHUMAN WEEK #10 (CLASS 6550)

COMPREHESIVE I HUMAN CASE

STUDY 62-YEAR-OLD REASON FOR

ENCOUNTER I’M PEEING ALL THE TIME

(CLASS 6550) WEEK

COMPREHESVE I HUMAN CASE STUDY 62-YEAR-OLD REASON

FOR ENCOUNTER I’M PEEING ALL THE TIME (CLASS 6550)

WEEK

Includes : History of Present Illness, Physical Exam, Differential Diagnosis, and Management

Plan, location , outpatient clinic with x-ray , ecg and laboratory capabilities, assessment, test results, diagnosis, plan & summary

| IHUMAN WEEK #10 (CLASS 6550)

Patient Information

• Name: 62-Year-Old Male
• Height: 6'1" (185 cm)
• Location: Outpatient Clinic with access to X-ray, ECG, and laboratory capabilities
• Reason for Encounter: Frequent urination – "I’m peeing all the time."

| IHUMAN WEEK #10 (CLASS 6550)

3. Have you experienced any changes in the frequency of urination over time? "Yes, the frequency has definitely increased. Initially, I would go to the bathroom 3-4 times during the day, but now it’s much more often, sometimes every hour or so. It feels like my bladder just doesn’t hold as much."
4. Is the frequent urination happening more during the day or at night? "It’s mostly at night. I wake up at least 3-4 times every night to go to the bathroom. The daytime frequency isn’t as bad, but it still seems to have increased."
5. Do you wake up during the night to urinate? If so, how many times per night? "Yes, I wake up at least 3 times every night. Sometimes it’s even 4 times. It’s really disrupting my sleep and making me feel more tired during the day."
6. Are you experiencing any urgency to urinate, or do you feel the need to go suddenly? "Yes, sometimes I feel like I have to go urgently, and if I don’t go immediately, it becomes really uncomfortable. It’s like my bladder is pressing to go."
7. Is there any pain or burning sensation when you urinate? "No, there’s no pain or burning. It’s just the constant need to go, especially when I feel the urgency."
8. Do you ever feel like you haven’t fully emptied your bladder after urinating? "Yes, sometimes I feel like I haven’t fully emptied my bladder after I go. I might have to go again within a short period, and it feels like there’s still some pressure."
9. Have you noticed any changes in the color or appearance of your urine? "No, my urine looks normal. There’s no discoloration or cloudy appearance. It looks just like it always has."
10. Have you had any difficulty starting or stopping urination?

| IHUMAN WEEK #10 (CLASS 6550)

"Not really. It’s mostly about the frequency and urgency. I don’t have trouble starting or stopping the flow; it’s just the constant need to go."

11. Do you experience any dribbling or leakage of urine after you finish urinating? "No, I don’t experience any dribbling or leakage after going. It’s just frequent urination."
12. Have you had any recent changes in your diet or fluid intake? "I’ve been drinking a lot more coffee lately, especially in the mornings, but nothing too unusual in terms of diet. I also drink water, but I probably could cut down on the coffee."
13. Do you consume alcohol or caffeine regularly? "Yes, I drink coffee every morning, and I have a beer or two in the evening a few times a week. I don’t drink excessively, but I’ve been having a bit more coffee lately."
14. Have you experienced any weight changes recently? "I’ve gained a few pounds recently, but nothing drastic. My weight has been pretty stable overall."
15. Have you had any recent fever or chills? "No, I haven’t had any fever or chills. I haven’t been feeling ill."
16. Have you noticed any swelling in your legs or ankles? "No, I haven’t noticed any swelling in my legs or ankles. I’m not retaining fluid, as far as I can tell."
17. Do you have any other medical conditions, such as heart or kidney disease? "I have high blood pressure and diabetes, but other than that, no major medical issues. My blood pressure is controlled with medication, and my diabetes is managed with metformin."

| IHUMAN WEEK #10 (CLASS 6550)

• Increased Frequency: The patient reports an increase in urinary frequency, initially experiencing 3-4 daytime voids but now urinating every hour or so.
• Nocturia: The patient experiences frequent nighttime urination, waking up at least 3- times per night, which significantly disrupts his sleep pattern.
• Urgency: The patient experiences occasional urgency to urinate, which can be uncomfortable and requires immediate attention.
• Absence of Pain or Burning: There is no associated pain, burning, or discomfort during urination.
• No Hematuria: The patient denies noticing blood in the urine, as well as fever, chills, or abnormal discharge.

Exacerbating Factors:

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• Caffeine and Fluid Intake: The patient has noticed that consuming large amounts of fluids, particularly caffeinated beverages like coffee, exacerbates the urinary frequency and urgency.

Relieving Factors:

• Reduced Fluid Intake: The patient reports that reducing fluid intake, especially caffeinated drinks, provides temporary relief by decreasing the frequency of nighttime urination. Additionally, urinating more frequently during the day helps reduce the urgency at night.

Associated Symptoms:

The patient does not report other symptoms such as fever, pain, or blood in the urine. There is also no indication of significant weight loss or fatigue, which would be concerning for more serious conditions like uncontrolled diabetes, malignancy, or infection.

| IHUMAN WEEK #10 (CLASS 6550)

Family History

• Father: Had prostate issues, including BPH, and later developed prostate cancer.
• Mother: Type 2 diabetes, hypertension.
• No known history of urinary tract cancers or other hereditary urological diseases.

| IHUMAN WEEK #10 (CLASS 6550)

Social History

• Smoking: Occasional smoker, ~5-7 cigarettes per week.

| IHUMAN WEEK #10 (CLASS 6550)

Review of Systems:

• General: No fever, chills, night sweats, or unintentional weight loss.
• Cardiovascular: No chest pain or palpitations.
• Gastrointestinal: No nausea, vomiting, or changes in bowel habits.
• Genitourinary: As detailed in HPI – frequent urination, urgency, nocturia.
• Neurological: No headaches, dizziness, or blurred vision.
• Musculoskeletal: No significant joint pain or discomfort.

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Physical Exam

• Vital Signs:

o Blood Pressure: 130/85 mmHg o Heart Rate: 76 bpm, regular o

Temperature: 98.6°F (37°C) o Respiratory Rate: 16 breaths/min o

Weight: 200 lbs (90.7 kg) o BMI: 26.6 (Overweight)

| IHUMAN WEEK #10 (CLASS 6550)

Differential Diagnosis

Given the patient's age and presenting symptoms, several potential diagnoses should be considered:

1. Benign Prostatic Hyperplasia (BPH): Likely contributing to increased frequency and nocturia, especially with a known history of BPH.
2. Overactive Bladder (OAB): Increased frequency and urgency without significant pain could point to OAB, especially since nocturia is prominent.
3. Diabetes (Uncontrolled or New Onset): Diabetes can cause polyuria due to high blood glucose levels. The patient has a history of type 2 diabetes, and uncontrolled blood sugar can lead to increased urination.
4. Urinary Tract Infection (UTI): Although the patient denies pain or burning, UTIs can cause frequent urination. This is less likely given the absence of fever or pain.
5. Bladder Stones or Obstruction: Chronic urinary frequency could be related to bladder stones, although the absence of hematuria or significant pain makes this less likely.
6. Prostate Cancer: Though less likely given the smooth, non-tender prostate on DRE, prostate cancer can cause similar urinary symptoms, especially with a family history.
7. Medications/Diuretics: If the patient is on diuretics for hypertension, this could contribute to increased urination. However, this was not specifically mentioned.

| IHUMAN WEEK #10 (CLASS 6550)

Diagnostic Work-Up

Given the differential diagnoses, the following tests are recommended:

1. Urinalysis: To check for signs of infection, hematuria, or glucose.
2. Post-Void Residual Volume (PVR): To assess if the patient is fully emptying his bladder.
3. Prostate-Specific Antigen (PSA): To screen for prostate cancer.
4. Serum Glucose and HbA1c: To assess the control of diabetes.
5. Transabdominal Ultrasound: To assess for bladder stones or other structural abnormalities.
6. Urodynamic Studies: If overactive bladder is suspected and symptoms persist.

| IHUMAN WEEK #10 (CLASS 6550)

1. BPH Management:

o Start Alpha-blockers (e.g., tamsulosin) to relax the prostate and bladder neck muscles, improving urinary flow.

o Consider 5-alpha reductase inhibitors (e.g., finasteride) if symptoms worsen or if significant prostate enlargement is noted.

2. Overactive Bladder (OAB) Management:

o Recommend antimuscarinics (e.g., oxybutynin) for urgency and frequency if overactive bladder is suspected.

o Suggest bladder training and scheduled voiding to improve bladder control.

3. Diabetes Control:

o Monitor HbA1c and optimize diabetic control. If blood sugars are poorly controlled, adjust medications accordingly.

4. Lifestyle Modifications:

o Recommend reducing caffeine intake, especially in the late afternoon/evening.

o Encourage regular physical activity to improve overall health and bladder function.

5. Follow-Up:

o Schedule a follow-up appointment in 4-6 weeks to assess symptom improvement.

| IHUMAN WEEK #10 (CLASS 6550)

Test Results (Pending)

• Urinalysis: Pending
• PSA: Pending
• Blood Glucose and HbA1c: Pending Assessment and Diagnosis
• Primary Diagnosis: Likely Benign Prostatic Hyperplasia (BPH) contributing to the urinary symptoms.
• Secondary Diagnosis: Consider Overactive Bladder (OAB), potential uncontrolled diabetes, and need to rule out UTI or other structural issues.