History of Present Illness
| Category | Data entered by Ann Finecountry |
| Reason for Encounter | I’m peeing all the time. |
| History of present illness | The patient is a 62-year-old man with hyperlipidemia and hypertension. For the last six weeks, he has had increased urinary frequency, hesitancy, and urgency. He goes to urinate at least every two to four hours throughout the day. Besides, half the time, he cannot make it two hours in between peeing. At night, he wakes up to urinate at least twice and takes 30 minutes to fall back asleep. As a result, he gets an hour or more less of sleep every night. About half the time in the past month, he has had an incomplete sense of bladder emptying. Besides, every time he urinates, urine takes a while to start and dribbles at the end of urination and in every 1 in 5 times, his stream starts and stops. However, the amount he urinates is the same but a little less with every trip to the bathroom. Patient informs that his father and paternal cousin, who are both deceased, had prostate cancer. He further denies increased oral intake of fluids than usual, malaise, night sweats, fevers, weight loss, weight gain, palpitations, shortness of breath (SOB), cough, abdominal pain, flank pain, nausea, vomiting, involuntary bowel movements, urinary incontinence, blood in urine, or urethral discharge. |
Past Medical History
| Category | Data entered by Ann Finecountry |
| Past Medical History | Has underlying hypertension (HTN) and hyperlipidemia. He was diagnosed with HTN at 42 years old and hyperlipidemia 4 years later. |
| Hospitalizations / Surgeries | denies undergoing any surgeries, denies hospitalizations for any chute or chronic illnesses. |
Medications
| Category | Data entered by Ann Finecountry |
| Medications | Rosuvastatin 20mg PO 24 hourly for hyperlipidemia Amlodipine 10mg PO 24 hourly for hypertension. Denies herbal drug use Denies OTC drug use. |
Allergies
| Category | Data entered by Ann Finecountry |
| Allergies | Denies known/unknown medication or food allergies. Allergic to bees, wasps and hornets. Reports swelling and getting a bubonic plaque with lumps and bumps. |
Preventive Health
| Category | Data entered by Ann Finecountry |
| Preventive health | uptodate with all immunizations; COVID & flu. |
Family History
| Category | Data entered by Ann Finecountry |
| Family History | Mother deceased (86 years old) PMH of COVID, heart failure, and diabetes mellitus (DM). Father deceased (72 years old) had PMH of prostate cancer and hypertension. Paternal cousin (deceased) with a PMH of prostate cancer. Has 2 sisters; 60 and 64years old. Former has a PMH of a heart murmur and later has a PMH of diabetes mellitus (DM) and kidney disease. |
Social History
| Category | Data entered by Ann Finecountry |
| Social History | in a monogamous marriage. Has a wife and two children. Lives with wife and youngest child aged 23 years old. Worked at a steel fabrication company for more than 40 years. Hasn’t smoked tobacco in 4 decades after quitting in his 20s. Acknowledges taking a beer one or two nights weekly, denies recreational/illicit drug use. |
