iHuman Case Study 62-Year-Old with Frequent Urination (I’m Peeing All the Time), Exams of Nursing

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Evan Tyson Ihuman Case

Peeing at Night and Fatigue

65 y/o

6' 0" (183 cm) 216.0 1b (98.2 kg)

Reason for encounter Peeing at Night and Fatigue Tired and peeing at night

Submitted on 08/14/

Case authored by: Steven Durning, MD, PhD, FACP

X Assoc^ sx

Have you gained or lost weight unintentionally, despite normal appetite and exercise? Well, when I retired, I just sat around too much and gained quite a bit of weight, tipped the scales at about 220. But, over the last couple of weeks, I've lost 4- pounds without really trying. It's weird... the funny thing is that I have been eating a lot and not sure how that happened. Maybe it is all water weight I've been losing peeing. What do you think?

X Etiology^

How much water/fluids do you drink in a day? About^4 liters^ a^ day.

X Etiology^

How is your appetite? Any recent change? It's^ definitely^ increased.

History Physical Exam Assessment Test Results Diagnosis Plan Summary

History Physical Exam Assessment Test Results Diagnosis Plan Summary x PMH^ Any new or recent change in medications?

No. I don't have any regular

prescribed meds.

x PMH^ Are you taking any over-thecounter or herbal medications? Just multivitamins and a few supplements. Nothing like steroids, you know; just some additional vitamins. x PMH^ Do^ you^ have^ any^ allergies?^ Not that I know of.

Asked X Not asked

Review of Systems (ROS)

Select the major body systems that have not been touched on during the interview process for the HPI.

Asked X Not asked

History Physical Exam Assessment Test Results Diagnosis Plan Summary

Graded Question Response Information Clinic Notes^ Obtained

X

Have you noticed any bruising,

bleeding gums, nose bleeds, or

other sites of increased bleeding?

Uh...no.

Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? No. Well I'm tired so dont want to exercise much. Is that what you want to know? x Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production?

No.

x Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating?

That sounds nasty. I dont have

any of that.

EHR Show Dialogue Hx Notes See Patient Proceed

History Physical Exam Assessment Test Results Diagnosis Plan Summary Exams Feedback O Performed Correctly

• auscultate abdomen o You performed the simulation correctly.
• auscultate heart o You performed the simulation correctly.
• Your documentation was correct.
• blood pressure
• genitourinary male exam Erectile abnormalities can result from low testosterone levels which might be seen in testicular volume.
• orthostatic blood pressure (BP)
• palpate abdomen Palpation of the abdomen is to evaluate for:
• organomegaly (liver and spleen) o aorta diameter
• pulse
• test visual acuity Visual acuity is important in any person that presents with a complaint of a visual problem.
• visual inspection abdomen Abdominal inspection is looking for abdominal hernias and other vascular markers.
• visual inspection extremities A comprehensive visual inspection of the lower-extremities should address all of the following: o Signs of impaired peripheral perfusion and/or oxygenation, including secondary signs of poor healing and skin breakdown/ulceration o Signs of fluid overload o Signs of impaired venous return o Musculoskeletal pathology: muscle wasting, joint swelling or inflammation Other skin, nail, and hair changes Several historical factors should prompt visual inspection of this patient's lower extremities: o Altered fluid status o Symptoms suggestive of diabetes mellitus

History Physical Exam Assessment Test Results Diagnosis Plan Summary

• auscultate lungs o You did not perform any simulation.
• You did not document anything for left lung.
• You did not document anything for right lung.
• inspect eyes In a complaint of a visual problem, start with inspection looking for signs of edema, redness or tenderness that would suggest an infectious process.
• inspect hair color, distribution, thickness Erectile difficulties can be due to hormonal, vascular or psychologic problems. Therefore, evaluating a patient for changes in male hair distribution and thickness (indicative of testosterone stimulation) can provide evidence to increase or decrease one's suspicion for a hormone disturbance.
• look in eyes with ophthalmoscope There are many causes of blurred vision, see list below, so it is important to do a fundoscopic exam to directly exam the retina and optic nerve for serious treatable problems. Acute maculopathy Optic neuritis Multiple sclerosis

Papilledema

Chiasmal problems

Lens changes

Dirty contacts

Hyperglycemia

Psychogenic

• measure girth Abdominal obesity is an independent risk factor for type 2 diabetes mellitus as well as being at increased risk for heart disease, hypertension, dyslipidemia and nonalcoholic fatty liver disease. Prevailing guidelines define abdominal obesity in terms of waist circumference:
• Women: 35" (88 cm) or greater o Men: 40" (102 cm) or greater
• monofilament test The monofiliment test is a simple way to quantify the degree of sensory deficits as a specific pressure is needed to result in the bending of a filament.
• palpate neck o The thyroid should be evaluated for overall size, consistency, and palpable irregularities (nodules).
• reflexes - deep tendon An extremity neurologic exam is important in any patient that presents with peripheral extremity complaints.
• You did not perform any simulation.
• sensory tests (light touch, pain, position, temperature, vibration)

History Physical Exam Assessment Test Results Diagnosis Plan Summary Sensory testing includes: light touch, pain, position, temperature and vibration. The type of test is documented as well as the extent (location) of any abnormal findings. It is also important to determine if a deficit is bilateral versus unilateral.

History Physical Exam Assessment Test Results Diagnosis Plan Summary Organize Key Findings

Your Findings Case Findings

Feedback

The medical key findings list you have compiled should this patient, even when it is not a "problem" in the true problem (MSAP) may be difficult to determine as many and cardiovascular collapse if the patient's access to MSAP from the physician's perspective may not be the attention. The cause of polyuria is short and includes solute diuresis can cause this polyuria are glucose and urea. What other increased risk of having hyperglycemia or elevated blood Write Problem Statement

Select

Problem Categorie Select Differential

Diagnosis

Rank

Differential

Diagnosis

Select Tests

Key Finding MSAP

Relation

Nocturia MSAP

Fatigue (^) RELATED Erectile Disfunction (^) RELATED Blurry Vision (^) RELATED

Key Finding MSAP

Relation

Polyuria MSAP

Polydipsia (^) RELATED Numbness and paresthesias of feet (^) RELATED

Blurred vision: decreased visual acuity

per exam

RELATED Sexual (erectile) dysfunction (^) RELATED

Diminished vibratory sensation to

level of knees; diminished light-

touch sensation in the feet

RELATED Increasing fatigue x weeks to months (^) RELATED

History Physical Exam Assessment Test Results Diagnosis Plan Summary What hormone is important for water maintenance? Does suggestive of an absence or resistance to this hormone? symptom in renal disease? What about the blurred vision linked to the polyuria? Finally, how does his fatigue, unintentional weight loss single unifying diagnosis or will it require two or more body fat and muscle loss? be a list that includes everything that is out of the ordinary about nse of the word. In this case, the most significant active are of ncern, but polyuria could result in severe dehydration water is ited, thus, this was chosen as the MASP. Note that the chief mplaint that brought the patient to seek medical or osmotic diuresis and polydipsia. Two common solutes that items on the key findings list would either put the patient at urea levels? What would the symptoms be for each? your key findings list contain any signs or symptoms Where does this hormone act? Isn't fatigue a common and erectile dysfunction? How might these symptoms be nd neurologic findings fit into this case? Can you identify a different agnoses? Is the weight loss due to water loss or real EHR Proceed

Central obesity: waist circumference

48"; BMI-29.

RELATED Elevated blood pressure (^) RELATED Unintentional weight loss 4-51bs (^) RELATED

Increased appetite UNKNOWN

Evan Tyson is a 65-year-old retired military male who complains of fatigue, thirst (4 liters water/day) and polyuria/nocturia,

blurred vision, peripheral neuropathy and erectile dysfunction of several weeks' to months' duration. He reports an