Male Genitalia Case Study Subjective: CC: “I’m having trouble with my bladder”. 72 year old African American male, normally in good health. Has been

Male Genitalia Case Study

Subjective:

CC: “I’m having trouble with my bladder”.

72 year old African American male, normally in good health. Has been gradually having

urinary complaints of difficulty starting his stream of urine, taking longer to empty his

bladder, and urgency with dribbling of urine. Tried taking Saw Palmeto, but hasn’t

noticed any improvement. Now has suprapublic pain since yesterday with urinary

burning, and terrible urgency to void for small amounts. Couldn’t sleep all last night with

running to the bathroom. Last general health exam was about 4 years ago. He hasn’t

needed any routine medications due to no chronic diagnoses and hates doctors and

especially rectal exams. Married happily for 49 years, but admits to having some

problems with maintaining erections during intercourse although he tries to initiate it

several times a week and his wife is a willing partner. No smoking, occasional ETOH, no

illicits. No relevant family history. He is a retired steel worker with medicare.

Objective:

T = 99 po, R = 16, P = 92, regular, B/P = 138/82

Tenderness to palpation over suprapubic area, no CVA tenderness, 100cc residual

bladder volume. Skin of genitaila is intact and evenly pigmented. No inguinal hernias

detected. Rectal exam reveals smooth rectal walls and enlarged prostate without

tenderness. Guiac neg. Moderate visiable hemoroids.

Urine dip – Mod amount of WBCs

Instructions

1. Prepare a SOAP note using the guidleines attached to the assignment link.

2. Submit the SOAP note to Blackboard- There is no ShadowHealth exam for the

breast.

3. Review the “Recording Information” PowerPoint which contains “tips for weekly

write ups”. You will be graded according to these tips.

4. If information is missing that you feel is important, you may add to the case study

facts as needed.

5. Your diagnosis and plan must be comprehensive and include the reference I

provided.

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