Order from us for quality, customized work in due time of your choice.
Case Scenario
Mr. M., a 54-year-old white insurance employee, sees a urologist and complains of pain when urinating. He comes to the appointment with his wife, who was the initiator of the visit to the medical specialist. According to the patient, in the last two months, he began to go to the toilet more often, especially at night, which he had not done before. In some cases, urination gives him discomfort in the form of cutting pain and a feeling of incomplete emptying of the bladder. After the urologist asks Mr. Ms wife to wait for him in the hallway, he asks the patient if he has had unprotected sex with another partner. Mr. M. denies this and argues that he has always been faithful to his wife. According to the results of the survey, the patient spends most of his working time in a sitting position. His body mass index is 36, and in addition to urinary problems, he also complains of high blood pressure. Family history confirms that Mr. M.s relatives had hypertension. Based on the interview and examination, appropriate tests are required to identify the root cause of health problems.
SOAP Note
Subjective
The patient and his wife state that previously, Mr. M. had no problems with urination. The patient notes that he did not have unprotected sexual intercourse with another partner. Complaints about frequent trips to the toilet and pain are supplemented by a remark about high blood pressure. Mr. M. talks about the strongest discomfort during frequent nighttime urination when he experiences a feeling of incomplete emptying of the bladder.
Objective
In accordance with the results of tests that detect sexually transmitted infections, there are no causative agents of venereal diseases in the patients body. The assessment of Mr. M.s physical condition indicates obesity and a predisposition to the development of arterial hypertension. The analysis for the diagnosis of the prostate gland to identify a common prostatic antigen confirms the presence of a first-stage prostate adenoma in the patient.
Assessment
The patients complaints are justified by the development of prostate adenoma. Associated risk factors, particularly obesity and a sedentary lifestyle, are crucial risk factors for the development of the disease (Kerr, Anderson, and Lippman 2017). Given that the form of Mr. M.s disease is not running, prostate adenoma is detected at the initial stage, which makes it possible to prescribe drug treatment without surgical intervention. Clinical data will be used to draw up an appropriate treatment plan, taking into account the individual characteristics of the patient.
Plan
The results of the tests and the general condition of the patient allow for choosing an individual treatment algorithm. In the case of Mr. M., the treatment course is conservative because the disease is detected at an early stage. To solve the problem, it is required to prescribe a combination drug therapy by using 5-alpha reductase inhibitors, alpha-blockers, and phytotherapeutic agents in the form of suppositories or capsules (Kim et al. 2017). These drugs are aimed at reducing the tone of smooth muscles. As a result of their action, the ducts of the urinary tract expand, which facilitates the process of emptying the bladder. The medications also convert testosterone into an active form, which prevents the growth of the prostate gland and eliminates relapses.
References
Kerr, Jacqueline, Cheryl Anderson, and Scott M. Lippman. 2017. Physical Activity, Sedentary Behaviour, Diet, and Cancer: An Update and Emerging New Evidence. The Lancet Oncology 18 (8): e457-e471.
Kim, Hyun Jung, Hwa Yeon Sun, Hoon Choi, Jae Young Park, Jae Hyun Bae, Seung Whan Doo, Won Jae Yang, Yun Seob Song, Young Myoung Ko, and Jae Heon Kim. 2017. Efficacy and Safety of Initial Combination Treatment of an Alpha Blocker with an Anticholinergic Medication in Benign Prostatic Hyperplasia Patients with Lower Urinary Tract Symptoms: Updated Meta-Analysis. PLoS One 12 (1): e0169248.
Order from us for quality, customized work in due time of your choice.