Discussion: Digital Rectal Exam

Discussion: Digital Rectal Exam

Discussion: Digital Rectal Exam

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Week 5 discussion PART 1 Mr. K. is a 70-year-old Native American male who presents with complaints of nocturia. He indicates that he has been waking up to urinate more than 3 times each night. In addition, he reports having urinary frequency during the day, starting and stopping a stream, and doesn’t feel like his bladder is completely empty after urination. He denies any pain on urination, fever or chills. His last PSA 2 years ago was negative. PMH: arthritis in both knees; takes over the counter ibuprofen as needed for joint pain. Social history: non-smoker; drinks 2-3 beers on the weekend Discussion Questions Part One What additional assessments/diagnostic tests might be helpful in the work-up? (patient’s chief complaint) Conduct a ROS on this patient. List your differential diagnoses. Share at least one tool that could be used to assess the severity of urinary symptoms in men. What primary diagnosis are you choosing at this point? PART 2 Physical Exam: Discussion Part Two (graded) Vital signs: blood pressure 140/80, heart rate 76, respirations 16, temperature 98.0; weight 210 pounds; height 5’9” General: no distress; no weakness or fatigue HEENT: unremarkable Heart: S1 and S2 RRR; no murmurs, gallops or rubs Lungs: breath sounds clear throughout lung fields Abdomen: soft, nontender with positive bowel sounds all 4 quadrants GU: negative CVA tenderness Rectal: digital rectal exam reveals enlarged prostate that is smooth and nontender For the primary diagnosis, what non-pharmacological and pharmacological strategies would be appropriate? Include the following: lab work and imaging studies Describe patient education strategies. Describe follow-up. Describe any referrals that may be necessary. Week 6 discussion PART 1 Ms. S. is a 62-year-old black female who has returned to the clinic to discuss her concerns that her lifestyle modifications to lose weight have not worked. At the last visit 3 months ago, she was advised to change her eating habits and increase activity to promote weight loss. She reports walking at least 30 minutes a day but has lost very little weight. She indicates that the walking only made her extremely thirsty and hungry and attributes her increased thirst and hunger to increased exercise and her increased urination due to drinking more water since “it’s been hot lately” and exercise makes me thirsty”. She has returned to the clinic to discuss if there is anything else that can be done to lose weight and to determine why she is so tired, thirsty and hungry all the time. She also thinks she may have an overactive bladder since she has to urinate frequently during the day, which has influenced her not to go on outings with her friends. Discussion Questions Part One Conduct a ROS on this patient. Indicate which symptoms are most concerning to you. List your differential diagnoses. What types of screenings would be appropriate to use based on the chief complaint? What primary diagnosis are you choosing at this point? PART 2 Physical Exam: Vital signs: blood pressure 145/90, heart rate 100, respirations 20 height 5’1”; weight 210 pounds Labwork: CBC: normal UA: 2+ glucose; 1+ protein; negative for ketones CMP: BUN/Creat. elevated; Glucose is 300 mg/dL Hemoglobin A1c: 12% Thyroid panel: normal LFTs: normal Cholesterol: total cholesterol (206), LDL elevated; HDL is low EKG: normal General: obese female in not acute distress HEENT: unremarkable CV: S1 and S2 RRR without murmurs or rubs Lungs: Clear to auscultation Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits Discussion Questions Part Two • For the primary diagnosis, what non-pharmacological and pharmacological strategies would be appropriate? • Include the following: lab work and screenings to be completed. • Describe patient education strategies. • Describe follow-up and any referrals that may be necessary. Week 7 discussion PART 1 C.G. is a 69-year-old male with a history of right head and neck cancer that you have been following for one year. The carcinoma was initially localized to the head and neck-specifically at the left lingual tonsil region and went on to complete a total of 6 weeks of radiation and chemotherapy. Recently, the last PET scan indicated some metabolic activity in the left lymph node area along with other regions of abnormal metabolic activity in the body-particularly the liver and the lungs indicating metastasis. C.G. indicates that he is tired of the effects of chemotherapy and radiation and does not want to pursue any more treatment for cancer. Background: Right head and neck cancer with metastasis to liver and lungs; patient is refusing further treatment. PMH: Hypertension Hyperlipidemia Stomatitis Anemia Neutropenia Current medications: Carvedilol 12.5 mg po 1 daily Furosemide 40 mg po daily Surgeries: 2012: right radical neck dissection Allergies: None Vaccination History: Influenza vaccine last received 1 year ago Received pneumovax at age 65 Received Tdap 5 years ago Has not had the herpes zoster vaccine Social history and Risk Factors: Former smoker-stopped smoking at the time his cancer was diagnosed-2 years ago Negative for alcohol intake or drug use Patient does not have an advanced directive or living will. He is refusing further treatment for his cancer and his wife and children are in disagreement with him. The patient wants to know what his options are for the remainder of his life. Family history: Negative Discussion Part One: Provide differential diagnoses (DD) with rationale. Further ROS questions needed to develop DD. Identify the legal/ethical issues involved with the patient and describe your approach to addressing end-of-life care for this patient.

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