Age/ sex :58years,Male.
Status: Overnight Observation.
Patient name: Kongo,Madugiri.
Chief Complaint: Frequent urination, urgency of urination, weak stream, difficulty with sleeping at night.
Secondary diagnosis dm,htn,hypothyroidism.
Isolation precautions: Standard precautions.
Risk for fall:None.
Advanced Directive: None. Patient refused.Copy in the chart.
Next of king: Amina Jenson.
Doctor:I am doctor Tumtum.What can I do for you?.
Patient: I am Mr Madugri.My ball,ball pointing fingers at his penis.
Doctor: Okay I understand .How old are you?.58years old.You have prostate problem. I will do your physical examination including checking your prostate. So the doctor did a digital rectal examination to determine the size of prostate and serum PSA test done,physical examination, eyes check, ears checked. He had a score of 19 from his prostate test.Other examination included general mental status, neuromuscular function, the sphincter tone.Also urinalysis to rule out cancer ,urinary infection,urethral syndrome, bladder stones and urethral stones done.
The doctor requested for interpreter. Someone that understand Nigeria language. Nigeria has 56 dialects. The general language of Nigeria is English. So interpreter is not needed. Moreover Mr Madugiri graduated from Columbia university of New York in 1972.You just have to listen and tell him to speak slowly.
Mr Madugiri complains of frequent urination, urgency, weak urinary stream and lower back pain.
(This is a noncancerous enlargement of the prostate gland. A 58years old man from Africa upper middle class came to visit his daughter in USA.His daughter decided to take him to the doctor for medical checkup and treatment. So she scheduled for physical assessment including prostate examination.)
The doctor orders to hydrate Mr Madugiri with 2liters of 0.9NS,and antibiotics given intravenously. And to monitor his output measurements and do post void residual immediately after voiding. If it is greater than 200ml teach patient how to self catheterization of himself.
Discharge in Am: Patient is educated on how to catheterize himself at home every six hours and how to prevent infection. Prescription given for BPH medication, catheter supplies and 24hours urine collection . The nurse also gives him supplies such as in and out catheter, and urinal while waiting for his supplies to arrive.
NB:Signs and Symptoms of BPH are :
Waking up at night to urinate
and Quality of life.