History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Next Steps
Test Result 1
Diagnosis
Treatment Orders
Question 1
Question 2
About the Case
70-yr-old male with nocturia
Physical Examination
General appearance
: Appears young for stated age and is in no acute distress.
Vital signs
:
Temperature 37° C
Pulse: 80/min
BP: 125/62 mm Hg
Respirations: 16/min
Height:5'11" (1.8 m)
Weight: 160 lb (72.5 kg)
BMI: 22.3
Skin
: Pink, warm, and dry to the touch. No rash.
HEENT
: Normocephalic with no evidence of trauma.
Pulmonary
: Breath sounds present and equal bilaterally. No stridor, rales, or wheezing.
Cardiovascular
: Heart rate is irregularly irregular. Radial pulses are present and equal bilaterally. No murmurs, rubs, or gallops.
Gastrointestinal
: Abdomen overall is soft, nontender to light and deep palpation. No guarding. No palpable bladder or suprapubic tenderness.
Genitourinary
: Circumcised phallus, bilateral descended testes which are normal in texture and without pain on palpation. Digital rectal exam shows approximately 70-g prostate gland that is smooth and with no identifiable central sulcus. No nodules or tenderness.
Musculoskeletal
: No costovertebral angle tenderness.
Neurologic
: Unremarkable
Mental status
: Alert and oriented to person, place, and time.
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