Transcript BPH - Dacy Gaston

BPH: Benign Prostatic
Hyperplasia
DACY GASTON
BPH
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Chief Complaint: “ I’ve been having difficulty urinating.”
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HPI: Patient D.W. is a 67 year old Caucasian male that presents to
the clinic with complaints of difficulty while trying to void. It has
been getting worse over the last year, and it has gotten to the point
where it is waking him up 2-3 times during the night. He also states
that when he gets up to void, only a small amount of urine is
produced.
BPH
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PMH:
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* Diabetes Type II diagnosed 2009
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* Hypertension diagnosed 2006
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* Hyperlipidemia diagnosed 2006
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Family History:
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Father: CAD, Diabetes, BPH
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Mother: Diabetes, HTN
BPH
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Medications:
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1) HCTZ 25 mg PO daily
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2) Lipitor 20 mg PO daily
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3) Metformin 500mg PO BID
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Allergies: NKDA
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Surgical History:
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Gallbladder removal 2000 unremarkable
BPH
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Social History: Denies recreational drug use. Has type 2 Diabetes
managed by Metformin. His sugars run 120-150 in the morning. He
drinks 2 glasses of wine a night. Does not exercise regularly but tries
to eat a healthy diet but states it is hard to when he works long hours
on the job. Works as a construction worker with long hours and
outside labor. Lives with his wife of 35 years. Has no children.
BPH
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ROS
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General: denies fever, chills, or headache fatigue.
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HEENT: denies headaches, dizziness, vertigo, fainting or
trauma. Last eye Exam was 6 months ago-normal. Denies
changes in vision, pain, redness, double vision or discharge.
Denies hearing impairment, tinnitus, earaches or infection.
Seasonal allergies with nasal congestion, otherwise denies
discharge, infection, nosebleeds or trauma. Last dental exam
6 months ago, cavity filling, otherwise denies sore throat,
voice changes, bleeding gums or hoarseness
BPH
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Skin: denies rash, itching, tingling, lesions or wounds.
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Neck: denies dysphagia, tenderness, pain, or masses
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Pulmonary: Denies dyspnea, cough, sputum, hemoptysis, wheezing or asthma.
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Cardiovascular: Denies palpitations, orthopnea, edema or murmurs.
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Gastrointestinal: denies reflux, vomiting. No change in stool pattern, denies bloodtinged stools, abdominal pain, constipation or diarrhea.
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Extremities: Denies coolness, tingling, loss of sensation or cyanosis.
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Vascular: Denies leg pain, swelling, leg cramps, ulcers or loss of hair on legs.
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Urinary: SEE HPI
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Musculoskeletal: Denies muscle or joint pain/tenderness/stiffness, muscle cramps,
gout or weakness. Full ROM.
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Neurological: Denies fainting, blackouts, weakness, paralysis, numbness, tremors,
loss of memory, unsteady gait or speech disorders.
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Endocrine: Denies thyroid disorder, heat or cold intolerance, changes in hair
growth.
BPH
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Objective
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Physical Exam:
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Vital Signs: BP 145/92 - HR 63 regular- RR 20 unlabored- Temp 98.7 –
O2 98%
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Height: 5ft 10inches
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Weight: 242
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BMI: 34.7-obese
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General: Patient is overweight Caucasian male who appears
moderately distressed at this time. He is AOx3, appropriately dressed
and aware of his situation and surroundings
BPH
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HEENT: Head nomocephalic without tinderness, lesions or lumps.
Hair evenly distributed, texture and quantity unremarkable. Facial
features symmetrical an overall unremarkable, no weakness noted.
PERRLA, EOM intact, Sclera clear, no redness or lesions present,
conjunctiva pink without excessive vascularity. Cornea clear, no
discharge or excessive tearing. Ear canals clear, no lesions or
tenderness noted. Tympanic membranes bilaterally pearly gray with
light reflex. No external exudate or bleeding. Rhinne: AC>BC
bilateral. Webber: midline no lateralization. Nose symmetrical with
no evidence of trauma. Nares patent, mucosa pink without
discharge or swelling. Mouth mucosa moist, pink without lesions,
tongue is midline, no coating or swelling present. Throat is moist,
pink, uvula rises midline symmetrically with mild obstruction of uvula,
gag reflex intact.
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Neck: Full ROM, trachea midline, thyroid unremarkable, no
lymphadenopathy.
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Skin: Somewhat flushed on face and cheeks, mild diaphoresis noted
on forehead and palms of hands. Cool and clammy to touch,
turgor good, nail beds pink with good capillary refill.
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Pulmonary: Lungs clear bilaterally, no crackles, ronchi, wheezing or
rales. Unlabored symmetrical respirations. Tactile fremitus normal
intensity and equal bilaterally. Percussion resonant in all lung fields.
Vesicular breath sounds heard throughout. No egophony,
whispered pectoriloquy or broncophony noted
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Cardiovascular: Examined seated and supine. No abnormal
pulsations, thrills or heaves noted. S1 louder at apex, S2 louder at
base. No extra heart sounds heard, no murmurs, rub or gallop.
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Vascular: No JVD. All pulses 2+ bilaterally in upper and lower extremities.
No bruits heard. Negative Homan’s sign bilaterally.
Abdomen: Obese abdomen otherwise unremarkable to inspection, no
visual abdominal pulsations. Normoactive bowel sounds in all 4
quadrants. Percussion dull from extra abdominal fat but noted
throughout. Liver span normal, no organomegaly noted. No masses
noted. No CVA tenderness noted. No bruit heard over aortic umbilicus.
Scar noted from gallbladder removal, otherwise unremarkable.
Genitourinary: DRE shows slightly larger than normal prostate margins,
with mild hardening of the prostate.
Extremities: Capillary refill <1 second, no edema, no clubbing noted. Full
ROM bilateral upper/lower extremity.
Musculoskeletal: Gain within normal limits, full ROM all extremities. Spine
midline with no deviation, normal curvature. No joint or muscle pain.
Neurological: AOx3 with no mental deficits noted. Cranial nerves intact.
DTR’s intact, 2+ upper and lower extremities. Sensory intact, no motor
deficits noted. Gait normal
BPH
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Differential/Diagnosis:
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1) BPH: ICD-9 600.0 : Benign prostatic hyperplasia (BPH) is an
histologic diagnosis that refers to the proliferation of smooth muscle
and epithelial cells within the prostatic transition zone (Gacci, et. al,
2014)
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2) Cystitis ICD-9 599.0
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3) Prostate Cancer ICD-9 185
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4) Overactive Bladder ICD-9 596.51
BPH
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Plan
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1) DRE-Done in Pt. assessment-feels abnormal. The DRE and the abnormal prostate
findings will need to be further worked up for Blood Test-PSA (American Urological
Association, 2010).
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2) Blood PSA test- In patients with bothersome symptoms, it is now recognized that
LUTS has a number of causes that may occur singly or in combination. Among the
most important are BPO, overactive bladder, and nocturnal polyuria (American
Urological Association, 2010).
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4) Watchful Waiting-Patients with mild symptoms of LUTS secondary to BPH (AUA-SI
score <8) and patients with moderate or severe symptoms (AUA-SI score ≥8) who
are not bothered by their LUTS should be managed using a strategy of watchful
waiting (AUA, 2010)
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3) Referral to Urology-If the initial evaluation demonstrates the presence of LUTS
associated with results of a digital rectal exam (DRE) suggesting prostate cancer,
hematuria, abnormal prostate-specific antigen (PSA) levels, recurrent infection,
palpable bladder, history/risk of urethral stricture, and/or a neurological disease
raising the likelihood of a primary bladder disorder, the patient should be referred
to a urologist for appropriate evaluation before advising treatment (AUA, 2010)
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References:
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American Urological Association. (2010). Guidelines: BPH
Management. Retrieved from
https://www.auanet.org/education/guidelines/benign-prostatichyperplasia.cfm
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Bradway, C., Bixby, M. B., Hirschman, K. B., McCauley, K., & Naylor, M. D.
(2013). Case Study: Transitional Care For a Patient with Benign Prostatic
Hyperplasia and Recurrent Urinary Tract Infections. Urologic Nursing,
33(4), 177-200.
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Gacci, M., Carini, M., Salvi, M., Sebastianelli, A., Vignozzi, L., Corona, G.,
& ... Serni, S. (2014). Management of Benign Prostatic Hyperplasia: Role
of Phosphodiesterase-5 Inhibitors. Drugs & Aging, 31(6), 425-439.