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Genitourinary Custom Essay

Care Plan Template

Patient Initials: ______ Age: _______________ Sex: ___________

Subjective Data:

Client Complaints:

HPI (History of Present Illness):

PMH (Past Medical History—include current medications, any known allergies, any history of surgery or

hospitalizations):

Significant Family History:

Social/Personal History (occupation, lifestyle—diet, exercise, substance use)

Description of Client’s Support System:

Behavioral or Nonverbal Messages:

Client Awareness of Abilities, Disease Process, Health Care Needs:

Objective Data:

Vital Signs including BMI:

Physical Assessment Findings:

Lab Tests and Results:

Client’s Support System:

Client’s Locus of Control and Readiness to Learn:

ICD-10 Diagnoses/Client Problems:

Advanced Practice Nursing Intervention Plan (including interdisciplinary collaboration, community resources and

follow-up plans):

References: Need at least 4 references
___________________________________________
Genitourinary Clinical Case HPI

A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been

experiencing this over the past two years, but for the past two weeks, the symptoms have increased significantly.

The current symptoms are similar to what he experienced in the past. However, for the past two weeks, he has had

increased nocturia, with decreased strength of urinary flow and slight terminal dysuria. Patient has had no

treatment in the past. The nocturia has been very troublesome over the past two weeks. Yesterday he had significant

difficulty in starting his urine flow and this is interfering with daily activities. He needs to pass urine four to

five times every night. He has been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work up in the past,

but now the symptoms have been increasing in severity. He believes he had a lowgrade fever yesterday. The patient

is not sure what is going on but thinks he may have cancer. He had significant obstructive symptoms two days ago.

Gradual worsening of symptoms has compelled him to seek medical help now.

PMH
Patient has not sought any medical care for this problem to date. He is being treated for hypertension and

hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five years ago as a

suspected case of angina. He was diagnosed with chest wall syndrome for which he was treated and then released.

There are no recent hospitalizations and no surgeries.

ROS
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in the stool. No

gross hematuria.

MEDICATIONS Cardizem 240mg daily Zocor 20mg daily Patient is compliant with the prescribed regimen and knows why he

is being treated.

ALLERGIES/REACTIONS No known drug allergies.

SOCIAL HISTORY
Patient has a master’s degree in engineering and his income is $65,000.00 per year. Though the patient is educated,

he lacks an understanding of resources available to him. Patient has no problems with finances. He has excellent

access to healthcare, but most often does not utilize the services to the extent that is expected. He has an

excellent health insurance coverage including a prescription plan. Patient is married and his spouse has excellent

general health. He has two grown-up sons who live with their own families. They are 35 and 37 years old, both alive

and well. Although the patient has a master’s in engineering, his knowledge of healthcare is inadequate. He

believes that he is generally healthy. His perception of self-efficacy is adequate. He has very little stress. His

support systems include his wife and friends from work who provide him with the required emotional support. There

is no family dysfunction. The patient is high strung and an over achiever. He gets little from social support

outside the home or work. Patient is originally from United States. He lives in a suburban setting. His resources

include his wife and the people he works with. Though there are other resources available to him, he is not sure

what they are.

HABITS
Smoking: Non smoker Alcohol: Does not drink Substance use: Denies substance abuse

DIET HABITS
His wife does most of the cooking. He believes that he gets adequate exercise, eats healthy, and maintains a

regular checkup regime with his physician.

WORK HABITS: He is an engineer and has always done the same work.

FAMILY HISTORY
He has one sister and one brother. Both are alive and well. There is a remote history of heart disease among his

aunts and uncles.

PHYSICAL EXAMINTAION Vital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt:

200#; Ht: 71”

HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border
Carotids: No bruits
Abdomen: Android obesity, non-tender
Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation. Genital/Pelvic:

Circumcised, no penial lesions, masses, or discharge.Testes are descended bilaterally, no tenderness or masses
Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.
Neurologic: Not examined
Lab Results/Radiological Studies/EKG Interpretation:
PSA: 6.0
CBC: WNL
Chem panel: WNL
Radiological Studies: None, EKG: None

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