List 3 (three) potential differential diagnoses for this patient's complaints. Include pertinent positive data and negative data from the case information. Would you add a medication to his regimen? Would you titrate or discontinue any of his current medications? What non-pharmacological therapies may be useful for this patient
CC: Up multiple times at night to urinate but only dribbles, lightheaded when standing up, sometimes can’t make it to the bathroom in time, difficulty with intimacy.
HPI: 65 year old white male present to clinic today with above complaints. Pt with long h/o UTIs and one episode of sepsis. Treated 2 weeks ago with Cipro 250 mg BID for 3 days. New complaint of erectile dysfunction. Denies fever, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, anorexia. Feels light headed when getting out of bed, but it resolves after a minute. Has not fallen. Denies spinning sensation. Denies chest pain, SOB, palpitations or diaphoresis.
PmHx: HTN, chronic UTIs, DM type 2, obesity, OA, insomnia
Meds: Metformin 1000 mg BID Terazosin 10 mg daily
Amitriptyline 25 mg qhs Metoprolol succinate 50 mg daily
Ibuprofen 800 mg BID Claritin D (24 hour) 1 tablet daily
Allergies: NKDA, cat dander
Vital Signs: BP = 110/60 HR = 65 RR = 18 Wt = 115.2 kg Ht = 6’0”
Physical Exam: no abnormalities
Labs: urine negative for glucose, nitrites, leukocyte esterases, WBC, RBC; trace bacteria present
|
Na |
136 |
Hgb |
12.6 |
AST |
12 |
|
K |
4.1 |
Hct |
37.9 |
ALT |
16 |
|
BUN |
9 |
WBC |
5.6 |
Alk Phos |
55 |
|
Creatinine |
0.7 |
TSH |
1.04 |
A1C |
7 |
|
Glucose |
120 |
Uric Acid |
3.5 |
PSA |
4.5 |
List 3 (three) potential differential diagnoses for this patient's complaints. Include pertinent positive data and negative data from the case information.
Would you add a medication to his regimen? Would you titrate or discontinue any of his current medications? What non-pharmacological therapies may be useful for this patient?
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