Care Plan
Subjective
The patient presents at the clinic complaining of nocturia, decreased urinary flow, decreased flow as well as terminal dysuria. TG states that the symptoms have been persistent for the last two years but the last two weeks have seen a significant increase in intensity of the symptoms. TG denies any case or instance of radiated pain within the period of two weeks,
Objective:
60 year old, Hispanic male
Vital signs: BP at 140/92;
Pulse rate: 80;
Temperature: 99.0
Weight = 200 pounds; height = 71”, BMI = 27.9
Patient Hx for hypercholesterolemia, hypertension, costochondritis, suspected angina, possible family history of heart disease in the family
Patient denies any use of alcohol, tobacco, or drug abuse
Current medication list: Cardizem 240mg QD and Zocor 20mg QD
Current Labs findings:
PSA 6.0
CBC WNL
CXR – none
EKG – None
Chem panel WNL
PE: Patient anxious but no acute distress identified but with Low grade fever
Abdomen: Android obesity, non-tender
Rectum: light brown stool, heme positive
Prostate: Enlarged boggy as well as tenderness on palpitation
Heart: RRR, with right sterna border Grade II/IV murmurs, ROS within normal range
Psychosocial assessment:
Patient is of Hispanic descent but originally a US resident. He is married and currently lives with the wife. He has two sons who are living independently with their families. TG educational background indicates that he has a master’s degree in Engineering. TG lives in a sub-urban residence and he indicates to be experiencing very little stress with a very supportive circle of family and friends. Patient has a health insurance cover and is financially stable and he regularly sees his primary care provider. He has poor grasp of health literacy and is unaware of the available resources that can support his health and wellness. Patient however has significant adherence to medication.
Nutrition and exercise:
TG takes most of his meals as prepared by the wife and he indicates that he considers that he has exercise enough for his health and his age
Diagnoses:
272.0 Hypercholesterolemia
790.3 Elevated PSA
601.0 Acute Prostatitis
600.00 Hypertrophy of prostate
401.9 Unspecified essential hypertension
599.00 UTI- Site not specified
300.00 Anxiety state unspecified
V74.5 Screen for venereal disease
327.01 Insomnia due to a medical condition classified elsewhere
785.2 Undiagnosed cardiac murmur
578.1 Blood in stool
Plan:
Assess the BPH with the use of the American Urological Association Symptom Index (Buttaro, Koeniger-Donohue & Hawkins, 2014)
Obtain the complete medical history including the bowel, sexual behaviors as well as bladder habits
Integrate additional medication to manage the BP preferably doxazosin
Perform neurological examination to rule out any case of any neurogenic bladder or associated disorder
Consider ciplofloxacin a broadspectrum antibiotic for the prostatitis
Consider the need for antipyretic or analgesic to manage the fever and pain, preferably paracetamol
Refer the patient to a cardiologist to ascertain the cause of the murmur and perform an EKG
Refer the patient to an urologist for a pelvic ultrasound examination and further evaluation
Order:
ECG
STI screen
Urinalysis with culture and sensitivity (U/A with c/s)
Colonoscopy for the heme stool
Integration of nutritionist to manage the BP and cholesterol
Consider need to integrate a mental health provider to manage matters of sexual dysfunction, depression associated with insomnia and anxiety
Education and Counseling:
On antibiotic treatment, patient needs to be informed of the need for adherence/compliance to snort that it is not lengthened (Jarvis, 2015)
Patient should be aware of the major disease processes and be able to monitor changes and report them to their primary care provider
Help the patient recognize the need for condom use to prevent any reintroduction of bacteria during sexual activity (Buttaro, Koeniger-Donohue & Hawkins, 2014)
Determine any foods, drinks and beverages that may aggravate the conditions and eliminate them from the patient’s care plan; insist on the need for a low-fat and low salt diet to manage the cholesterol and BP (Jarvis, 2015)
Provide the patient with useful resources such as a food guide pyramid as well as those suitable for prostate-associated disorders (Buttaro, Koeniger-Donohue & Hawkins, 2014)
Recommend and schedule a follow-up in 14 days to reassess and evaluate the symptoms and medication
Rationale
In this case, the patient’s differential diagnosis includes calculi, UTI, prostate cancer, obstruction, acute prostatitis and chronic prostatitis. Prostate cancer usually presents with back pain, enlarged prostate gland and hematuria and since this is absent in TG’s case, there is little likelihood of a cancer (Buttaro, Koeniger-Donohue & Hawkins, 2014). However, there is nocturia, fever, urgency and hesitancy which can all indicate prostate CA. Acute prostatitis may present with elevated PSA, fever, chills, malaise, dysuria, frequency nocturia, and enlarged/tender prostate. For chronic prostatitis, the most possible indications include tender/boggy prostate with all other signs and symptoms of acute prostatitis except for fever and chills. These are all indications as to the necessity of antibiotics, antipyretics, analgesics all which can eliminate the probable acute symptoms (Buttaro, Koeniger-Donohue & Hawkins, 2014).
References
Buttaro, T. M., Koeniger-Donohue, R., & Hawkins, J. (2014). Sexuality and quality of life in aging: Implications for practice. The Journal for Nurse Practitioners, 10(7), 480-485.
Jarvis, C. (2015). Physical examination & health assessment (6th ed.). St. Louis, MO: Saunders Elsevier.
