Question

J.R. is a 69-year-old male who goes to see his health care provider because he has been having difficulty urinating and dribbling for the past year, and it has gradually gotten worse. He has a history of hypertension and a myocardial infarction five years ago. He is currently taking the following medications:

• hydrochlorothiazide (Diovan HCT) 25 mg PO every morning
• metoprolol (Lopressor) 50 mg PO BID
• potassium Chloride (K-tab) 20 mEq PO daily
• aspirin (A.S.A.) 81 mg PO daily

Subjective Data

• Has difficulty starting to urinate and when the urine flow does start, it is a slow stream, the urine flow stops and starts several times while voiding, and there is dribbling at the end
• Gets up at least twice per night to void
• Has been going on for about one year and has increasingly gotten worse
• Diagnostic Studies

Urinalysis with culture:

• Color: Amber yellow
• Odor: Aromatic
• Protein: Trace
• Glucose: None
• Ketones: None
• Specific gravity: 1.018
• pH: 6.2
• RBCs: 3/hpf
• WBCs: 1/hpf
• Casts: Present
• Bacteria: None
• PSA 3 ng/mL
• Post void residual by bladder scan 175 mL

Collaborative Care:

• Transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH)

1.The write his or her patient report and share it with the nurse coming in. Please very descriptive.

Answer 1

Nurse's note

The pt jr was received at the morning , 69-year-old male . He was having a difficulty urinating and dribbling for the past year and it has gradually gotten worse. Pt was had MI and HTN five yrs ago. Presently he is taking hydrochlorothiazide (Diovan HCT) 25 mg PO every morning metoprolol (Lopressor) 50 mg PO BID potassium Chloride (K-tab) 20 mEq PO daily aspirin (A.S.A.) 81 mg PO daily

Urinalysis show acidic ph and no UTI but PSA of 3ng/ml ( slight) , bladder scan show 175ml residual volume which may be due to prostate hypertrophy