Male Genitalia Case Study
Subjective:
CC: “I’m having trouble with my bladder”.
72 year old African American male, normally in good health. Has been gradually having
urinary complaints of difficulty starting his stream of urine, taking longer to empty his
bladder, and urgency with dribbling of urine. Tried taking Saw Palmeto, but hasn’t
noticed any improvement. Now has suprapublic pain since yesterday with urinary
burning, and terrible urgency to void for small amounts. Couldn’t sleep all last night with
running to the bathroom. Last general health exam was about 4 years ago. He hasn’t
needed any routine medications due to no chronic diagnoses and hates doctors and
especially rectal exams. Married happily for 49 years, but admits to having some
problems with maintaining erections during intercourse although he tries to initiate it
several times a week and his wife is a willing partner. No smoking, occasional ETOH, no
illicits. No relevant family history. He is a retired steel worker with medicare.
Objective:
T = 99 po, R = 16, P = 92, regular, B/P = 138/82
Tenderness to palpation over suprapubic area, no CVA tenderness, 100cc residual
bladder volume. Skin of genitaila is intact and evenly pigmented. No inguinal hernias
detected. Rectal exam reveals smooth rectal walls and enlarged prostate without
tenderness. Guiac neg. Moderate visiable hemoroids.
Urine dip – Mod amount of WBCs
Instructions
1. Prepare a SOAP note using the guidleines attached to the assignment link.
2. Submit the SOAP note to Blackboard- There is no ShadowHealth exam for the
breast.
3. Review the “Recording Information” PowerPoint which contains “tips for weekly
write ups”. You will be graded according to these tips.
4. If information is missing that you feel is important, you may add to the case study
facts as needed.
5. Your diagnosis and plan must be comprehensive and include the reference I
provided.
