course materials

1. Chronic Obstructive Pulmonary Disease Research
Chronic Obstructive Pulmonary Disease ResearchChronic Obstructive Pulmonary Disease
ResearchChronic obstructive pulmonary disease with (acute) exacerbation. (ICD-10-CM J44.
1)Urinary tract infection, (ICD-10-CM N39. 0)Type 2 diabetes mellitus without
complications (ICD-10-CM E11.9).Hyperlipidemia, Unspecified (ICD-10-CM E78.5).Acute
Bronchitis, Unspecified. Code J20. 9Please use the attached template and the differential
diagnosis most have ICD -10 codes .Thank you in advance .ORDER NOW FOR CUSTOMIZED,
PLAGIARISM-FREE PAPERSMartha Suarez del Villar Miami Regional University Date of
Encounter: 07/22/2020 Preceptor / Clinical Site: Yoel Enriquez,ARNP Clinical Instructor:
Dr. Kirenia Santiuste DNP, APRN Soap Note BENIGN PROSTATIC HYPERPLASIA PATIENT
INFORMATION Name: M.H Age: 77-year-old Gender at Birth: Male Gender Identity: Male
Source: Patient Allergies: Sulfas causing rashes Current Medications: • Amlodipine m5 g
every day • Atorvastatin 20mg every day PMH: Mr. H. presently being treated for, HTN and
hyperlipidemia. The patient denies a history of cancer or renal disease. Immunizations:
Influenza October 2019, HZV 2019 Preventive Care: Coloscopy 1 years back (Negative)
Surgical History: Appendectomy in the 30s. Family History: Mother-died at 75 from the MI
Father- died at 83 from Prostatic Cancer Daughter -alive and healthy, 45 years old Social
History: 22 pack-year history but quit 4 years ago. Social drinking. Married and retired.
Sexual Orientation: Straight Nutrition History: Follow healthy diet Subjective Data: Chief
Complaint: ““At night, I have to go to the restroom 5-6 times”. Symptom analysis/HPI: Male,
Hispanic, white patient, 77 years old states that over the most recent 5 months he had the
impression of not empty his bladder totally after he complete the process of urination, he
needed to go to pee again in under one hour, and he need to push or strain to start pee and
start again a few times during urination. He noticed that the stream is weak, however he
can’t delay pee and needs to get up an average of 5-6 times each night. Review of Systems
(ROS) CONSTITUTIONAL:Chronic Obstructive Pulmonary Disease ResearchStable weight in
the most recent year and he keep doing likewise routine of activity without weakness. No
fever. NEUROLOGIC: Denies headache and dizziness. Denies changes in LOC. Denies a
history of tremors or seizures. HEENT: HEAD: Denies any head injury, or change in LOC.
Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears.
Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT:
Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY: Patient denied
cough, blood in the sputum or shortness of breath. No history of any respiratory disease
recently CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal

2. nocturnal dyspnea. GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies
flatulence, nausea, vomiting or diarrhea. GENITOURINARY: Denies hematuria and dysuria
.Subject states a change in urinary frequency. He had difficulty starting/stopping stream of
urine and incontinence the last 5 months MUSCULOSKELETAL: Denies falls or pain. Denies
hearing a clicking or snapping sound. SKIN: No change of coloration such as cyanosis or
jaundice, no rashes or pruritus Objective Data: VITAL SIGNS: Temperature: 97.8 °F, Pulse:
72, BP: 115/73 mmhg, RR 18, PO2-99% on room air, BMI 26.6. GENERAL APPEARANCE:
The patient appears tachypneic but has no accessory muscle use. NEUROLOGIC: Alert, CNII-
XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and
lower extremities. Bilateral UE/LE strength 5/5. Chronic Obstructive Pulmonary Disease
ResearchHEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary
sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and
extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent
without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray
with a sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa dry without lesions. Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid
swelling or masses. CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop
noted. Capillary refill < 2 sec. No lower extremity edema. Radial pulses and DP equivalent
bilaterally. RESPIRATORY: Respirations regular in 1-minute, good chest expansion no
asymmetric. Lugs sounds are clear, not auscultate any rales in all pulmonary fields. No use
of accessory muscles. GASTROINTESTINAL: No mass or hernia observed. Upon auscultation,
bowel sounds present in all four quadrants. No bruits over renal and aorta arteries.
Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted
on palpation GENITOURINARY: Digital rectal exam reveals normal tone of the sphincter, no
hemorrhoids or tumor were palpated. Prostate, no painful symmetric, with rubbery and
smooth surface impress increased in size and free from nodule. MUSCULOSKELETAL: No
pain to palpation. Active and passive ROM within normal limits, No stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice. ASSESSMENT: Main
Diagnosis: Benign prostate hyperplasia (N40.1, ICD-10): this patient is a 77 YO male with
lower urinary symptoms, at digital rectal exam: enlarge prostate with rubbery and smooth
surface, no tender, no nodules, no calcifications, labs and images exams that reveals a
benign characteristic of the prostate. Differential diagnosis: 1. Prostate cancer (C61, ICD-
10): Prostate asymmetric at digital exam with prostate nodules and calcifications,
laboratory test showed elevated PSA for age. (Mayo clinic, 2019) 2. Prostatitis (N41.0, ICD-
10): Patient with infection picture, fever, dysuria, malaise and blood in the semen,
suprapubic and lower back pain. Tender, edematous enlarged prostate gland at digital
exam. elevation of white count and abnormal urinary sediment (“What Is Prostatitis?”
2017) 3. Urinary tract infection (N39.0, ICD-10): Fever, chills, dysuria, lower back pain or
suprapubic with urinalysis and urine culture positive. (Verneda Lights and Elizabeth
Boskey, PhD, 2017.) PLAN: Labs and Diagnostic Test to be ordered: Lab tests WBC: No
alterations in normal ranges. Chemistry fasting: FPG: 108mg/dl HbA1C: 6.1%. The rest of
the analytic was in normal range (BUN and Creatinine normal) PSA: 4.9 mmol/l Urinalysis

3. micro/macro panel negative. Urine culture: No grow in 48 hours Special tests. • Chronic
Obstructive Pulmonary Disease ResearchTransrectal ultrasound: Gland symmetric, increase
in size, no calcifications or nodule, more than 150ml after void • Abdominal ultrasound: no
hydronephrosis or upper urinary tract alterations were noticed at this time • Cystoscopy:
Urethra and bladder without alteration • Urine flow and/or pressure studies: Decrease the
urine flow through the urethra, increase the bladder pressure to start void • PVR studies:
more than 150ml after void left in bladder • Prostatic biopsy: Pending. Pharmacological
treatment: The fundamental objective is to maintain a good quality of live and the treatment
is guided to improved urinary tract manifestations. Treatment of the constipation, bladder
training are behavior changes in this patient live in order to control urinary symptoms. It is
useful check patient’s prescription list so as to recognize meds that effect in BPH
manifestations. Limited caffeine and alcohol drinks. For patients with BPH progression the
management should be therapeutically or invasive to minimize the damage in the upper
urinary tract. Medical therapy Tamsulosin: alpha -blockers is well tolerate. Finasteride: 5-
alpha reductase inhibitors Surgical therapy or minimal invasive therapy such us:
Transurethral resection of the prostate (TURP). Transurethral microwave thermotherapy
(TUMT), Transurethral needle removal (TUNA), Laser treatment, prostatic urethral lift
(PUL) Patient should be referred to urologist if he has recurrent urinary manifestations or
complications such us bladder stones or renal insufficiency. If he has refractory responses
to medication or recurrent hematuria. Follow up consultation at least once a year. Non-
Pharmacologic treatment: Herbal medicines — Herbal therapies for BPH, such as saw
palmetto, are commonly used in Europe for treatment of BPH. However, the best studies of
saw palmetto have shown no benefit in reducing the symptoms of BPH. For this reason, we
do not recommend the use of saw palmetto or other herbal medicines to treat BPH
Education • Lifestyle changes — All men with BPH should avoid medicines that can worsen
symptoms or cause urinary retention. These include certain antihistamines (such as
diphenhydramine [Benadryl]) and decongestants (eg, pseudoephedrine [found in some cold
medicines]). • Lifestyle changes are also recommended if you are bothered by having to go
to the bathroom frequently. This includes: • Stop drinking fluids a few hours before bedtime
or going out. • Avoid or drink less fluids that can make you go more often, like caffeine and
alcohol. • Double void. This means that after you empty your bladder, you wait a moment
and try to go again. Do not strain or push to empty. Follow-ups/Referrals Urologist referral
for consultation and follow up References Buttaro, T. M. (2013). Prostatic Hyperplasia
(Benign). In Primary Care: A Collaborative Practice (5th ed., pp. 738-743). St. Louis, MO:
Elsevier Health Sciences. Benign Prostatic Hyperplasia (BPH): Practice Essentials,
Background, Anatomy. (2019, February 3). Retrieved from
https://emedicine.medscape.com/article/437359-overview. Mayo clinic. (2019, April 17).
Prostate cancer – Symptoms and causes. Retrieved from
https://www.mayoclinic.org/diseases-conditions/prostate-cancer Chronic Obstructive
Pulmonary Disease Research