CHINO M.

DELA CRUZ

Identifying Data

B. L., 71 years old, male, Filipino, Roman Catholic, currently residing at Purok 5,
Camague, Iligan City admitted for the 2nd time at GTMH last April 6, 2017

Informant: Patient

Percent Reliability: 90-95%

Chief Complaint: Difficulty Urinating

History of Present Illness:

The present condition started two weeks prior to admission as an onset of

difficulty in urination. Patient had to strain in order to urinate and experienced
urinary frequency and dribbling urine with a weak stream. One week prior to
admission, patient noticed his urine to be bloody. No medications were taken and no
consultation was done. Persistence of the symptoms prompted consult and
subsequent admission.

Past Medical History

On 2012, patient had laser ablation for benign prostatic hypertrophy at Maria
Reyna Hospital. On April 2016, patient had KUB utz which had the result of bilateral
nephrolithiasis and prostatomegaly. Patient did not take further action and no
medications were taken.

Family History

Patient has a positive family history of Diabetes and hypertension (paternal

side). No family history of other heredofamilial diseases such as asthma,
malignancy or thyroid diseases.

Personal/Social History

Patient was a smoker for 9 pack years but stopped smoking when he was 53
years old. He does not drink alcoholic beverages. His typical day includes staying
home most of the time, watching his grandchildren or going to the market
occasionally. His diet is composed of meat, fish and vegetables.

REVIEW OF SYSTEMS

General: (+) for weight loss; (-) for fever

Skin: (-) for rashes, bruises and scars

Head: (-) for headache, and dizziness

 Eyes: (+) for blurring of vision; (-) for photophobia and discharges

Ears: (-) for otalgia, tinnitus and discharges

Nose and sinuses: (-) for sinus area tenderness and discharges

Mouth and throat: (-) for hoarseness and dysphagia

Neck: (-) for rigidity and stiffness

Respiratory: (-) for cough, hemoptysis and dyspnea

Cardiac: (-) for chest pain and palpitation

Gastrointestinal: (+) for abdominal pain and melena; (-) for vomiting and
constipation

Urinary: (+) for dysuria, hematuria and dribbling urine, (-) for incontinence

Genital: (-) for discharges, itching and lesions

Musculoskeletal: (+) for joint pains; (-) for muscle weakness

Hematologic: (-) for bleeding and easy bruising

Neurologic: (-) for seizures and loss of consciousness

Psychiatric: (-) for depression and mood changes

PHYSICAL EXAMINATION

General Survey:

Patient is well-developed, poorly-nourished, conscious, coherent and not in

respiratory distress with the following vital signs:

BP: 110/70 mmHg

HR: 82 bpm

RR: 23 cpm

T: 36C

Skin:

warm to touch, no lesions, good turgor

Head:

normocephalic, no lesions, no masses

Eyes:

Anicteric sclerae, pinkish conjunctivae, PERRLA, no discharges

Ears

No tenderness, no discharges, tympanic membrane is intact

Nose and Sinuses

Septum is at midline, no nasal flaring, no discharges, no sinus area tenderness

Mouth and Throat

Slightly dry lips, moist oral mucosa, tonsils are not inflamed

Neck

Trachea is at midline, no carotid bruits, no thrills, no lymphadenopathies and neck

vein distention

Chest and Lungs

Inspection: equal chest expansion, no retractions

Palpation: equal tactile fremitus

Percussion: tympanitic on both lung fields

Auscultation: Clear bronchovesicular breath sounds

Heart

Inspection: PMI at 5th intercostal space, left midclavicular line

Palpation: no heaves or thrills

Percussion: CAD is not enlarged

Auscultation: distinct heart sounds with regular rhythm at a rate of 82/min

Abdomen

Inspection: scaphoid, no scars, lesions or visible veins

Auscultation: normoactive bowel sounds

Percussion: tympanitic all over

Palpation: no tenderness, no masses

Back
No CVA tenderness

Extremities

Equally strong palpable peripheral pulses on both upper and lower extremities, CRT
is <2 seconds

Digital Rectal Exam

good sphincter tone, no perirectal lesions, rectal vault without masses, prostate is
firm and non-tender, median sulcus slightly palpable, no nodules, no blood or stool
on examining finger.

PRIMARY IMPRESSION

Benign Prostatic Hypertrophy T/C Prostate CA

Benign Prostatic Hypertrophy usually presents as urinary frequency, urgency,

nocturia, hesitancy, incomplete emptying, straining in order to more fully evacuate
the bladder, subjective loss of force of the urinary stream and dribbling. These are
due to the obstruction caused by the enlarged prostate which is evident upon DRE.

DIFFERENTIAL DIAGNOSIS

Disease Considerations Rule Out

Prostatitis Obstructive urinary (-) fever, chills,
symptoms perineal/prostatic pain
(-) low back/low abdominal
pain
(-) tenderness upon DRE

Bladder Stone Dysuria (-) hematuria

Intermittency (-) suprapubic pain
Frequency
Nocturia
Bladder Cancer Irritative bladder (-) hematuria
symptoms (-) pelvic or bony pain
(-) flank pain
(-) lower extremity edema
(-) palpable mass