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Subject:NursingPrice: Bought3
C.C. "I am having burning with urination." HPI: T.B. 82 y.o. M reports
that he noticed burning with urination started about a week ago. Reports his stream is not affected. He also reports urgency with urination. Drinking lots of fluids without relief. Oxycodone is not helping with pain. He denies abdominal or flank pain. Denies fever, chills, lesions, hematuria or penile discharge. He has never had a urinary tract infection. PMH: Chronic pain syndrome, spondylosis of the lumbosacral region, and hypertension. Last colonoscopy was approximately 10 years ago per patient. Allergies: No known drug allergies. Medications: Oxycodone HCl 20 mg tablet; PO every 6 hours for pain, Atenolol 50 mg PO daily, Colace 100 mg capsule BID PO. Social History: He resides in an apartment for 50+. He is a non-smoker and denies recreational drug use. He drinks 2 beers every week He is sexually active with 1 partner. Does not use condoms. He drinks 2-3 cups of caffeine per day. He walks 30 minutes per day for exercise. Family History: Mother: deceased, HTN, smoker, CAD. Father: unknown history. Health Maintenance/Promotion: Influenza, TDaP, Hep A, shingrix vaccine up to date. ROS: General: Patient denies fever, chills, malaise, weight loss. Skin: Patient denies any recent rash, abnormal skin lesions, or open wounds. Neck: Patient denies neck stiffness or pain. HEENT: He denies any visual changes, ear pain or drainage, denies hearing loss, denies sore throat or nasal drainage. He reports last eye examination in August 2019 with minor changes to his vision. CV: Patient denies chest pain, chest tightness, heart palpitations or irregular heartbeats. He denies any swelling in lower extremities. He denies dizziness, syncope, or lightheadedness. Lungs: Patient denies any shortness of breath at rest or with exertion. He denies a cough. He denies wheezing or difficulty catching breath with exercise. GI: He denies abdominal pain, change in bowel habits, or noticing bloody or black colored stools. He denies constipation with long term opioid use. He reports that he has a bowel movement every morning. GU: Patient reports burning with urination and urgency started one week ago. He denies penile discharge or blood in urine. He denies flank pain. He denies incontinence, straining or dribbling urine. He denies splitting or spraying during urination. He denies intermittent urinary stream and feels like he is emptying his bladder. MSK: Patient denies muscle pain or aches. Neuro: Patient reports chronic pain is managed well with oxycodone that is prescribed by pain management. He denies any numbness or tingling, loss of coordination or balance. He denies any recent falls. He denies blurred or double vision. Psych: He denies little interest of pleasure in doing things and denies feeling down, depressed, or hopeless. Objective VS: Temp: 98.8 F, BP: 122/81 mm Hg, HR: 56 BPM, RR: 18, Oxygen saturation: 98% on Room Air, Ht: 69 in, Wt.: 200 lbs., BMI: 29.53 Index. General: Patient appears in no acute distress, well developed, well nourished. Skin: Skin is without redness, rash, or lesions. Head: Normocephalic. Neck: Neck supple; thyroid gland without enlargement. ENT: Both eyes, fundus normal. Ears: auditory canal intact and clear; tympanic membrane appears pearly grey. Oral mucosa pink and moist; throat without redness or exudate. CV: Regular rate and rhythm, normal S1 S2 without murmurs or clicks. No evidence of swelling in lower extremities. Radial and pedal pulses 2+. Lungs: Breath sounds clear on auscultation bilaterally. Chest expansion symmetrical without any evidence of respiratory distress. No wheezes, rhonchi, or rales heard on auscultation. Abd: Bowel sounds present in all quadrants. Abdomen soft, non-tender, and non-distended. GU: Male genitalia appears normal. Prostate: Digital rectal examination performed, prostate non-tender, no nodules and is of normal size. MSK: Normal muscle tone and bulk. Neuro: Coordination and balance intact. PERRLA. Muscle strength 5/5 in all extremities.
