Healthcare

Neurological & Male Genitourinary Disorders

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.

Case 1 Case 2 Case 3
Chief Complaint
(CC) “It burns when I urinate” “I had a severe headache yesterday with difficulty to speak” “I have been having frequents headaches lately”
History of Present Illness (HPI) A 68-year-old Caucasian male who reports to have increase on the frequency of urination with urgency for the last 5 days. He also present dysuria and nocturia. A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.
PMH Benning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatment Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin
Frequent headaches since I was 15, with menses.
Drug Hx Rosuvastatin 20 mg
Olmesartan 20 mg
Losartan 50 mg
Xarelto 15 mg BID
Ibuprofen for Headaches
Subjective
Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, dysuria.
Yellowish urethral secretion. Feels Palpitations, joint pain with yesterday’s episode Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day
Objective Data
VS B/P 150/96; Pulse 89; RR 16; Temp 99.4; Ht 6,1; wt 180; B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; B/P 108/64; Pulse 86; RR 16; Temp 98.6;

General well-developed male, no acute distress well-developed female, no acute distress 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room