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Nursing 8111 – Geriatric Male Adult Well Visit

 

Chief Complaint: “Adult well visit.”

HPI: 

A 66-year-old man presents to you, his PCP, for his annual adult well. There have been no dietary, social, or environmental changes in his life during the past year. He is not taking any prescription or over-the-counter medications. He states he generally feels well, exercises three times a week for 60 minutes a day and eats healthy organic foods as much as possible. He denies chronic illnesses or relevant medical history. The patient’s history is negative for major illnesses and trauma.

ROS: 

Positive for mild fatigue, decreased urinary stream, some urinary hesitancy, and occasional dribbling. His ROS is negative for fever, unexplained weight loss, SOB, polyuria, polydipsia, nocturia, dysuria, hematuria, urethral discharge, urinary urgency, urinary frequency, and incontinence.

His social history includes drinking 1 to 2 beers per week since age 20 and an average of 3 cups of coffee daily. The patient has been a bodybuilder since his 30s, working out with weights three times a week. He and his husband walk 2 miles together on most mornings. The patient has one sex partner (husband) and engages in both insertive and receptive anal sex 2 to 3 times a week. His family history is that his father died of prostate cancer at 68.

Allergies

No known drug allergies; no known food allergies.

Medications

None.

Physical Examination

Vitals: T 37.0°C, P 76, R 14, BP 122/80 mm Hg, HT 183 cm (72 in.), WT 82 kg, BMI 24.5.

General: Well-developed, well-nourished male in no acute distress.

Psychiatric: Appears slightly anxious and somewhat fatigued.

 

 

Skin, Hair, and Nails: No rashes or lesions. Hair and nails with no abnormal findings.

Eyes: Vision 20/20 with corrective lenses on Snellen test.

ENT/Mouth: Hearing grossly intact.

Neck: Thyroid not enlarged, no palpable nodules.

Chest: Chest expansion is symmetrical.

Heart: RRR without murmur or gallop.

Lungs: Clear to auscultation bilaterally.

Abdomen: Active bowel sounds; abdomen soft, non-tender; no masses.

Genital/Rectal: Uncircumcised male, no discharge or lesions, no scrotal or testicular masses. Soft, non-tender, symmetrical, boggy, 2+ enlarged prostate, loss of median sulcus; no palpable prostate nodules.

Musculoskeletal: No tenderness; full range of motion on BUE and BLE.

Neurologic: A&O, cranial nerves II to XII intact.

 

Critical Thinking Questions:

 

What is your differential diagnosis? Name your top three priority diagnoses. 
What is the most likely diagnosis? Why?
What diagnostic tests and imaging studies would you order? Why?

 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 8112

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