Follow the template Guidline
Case Study
Reason for encounter
Peeing problem
Location
Outpatient clinic with laboratory capabilities
History of present illness
This patient is 52 a 52-year-old male overweight male with PMH: type 2 diabetes, hypertension.
Who reports two months of difficulty maintaining an erection during intercourse. Symptoms are intermittent, and sex results in satisfaction, but reports reduced desire, alleviating and aggravating factors, and has not tried anything for relief.
He also reports one month of increased stress and fatigue, which he attributes to work and his children moving out of the house. He denies lower urinary symptoms, breast or penile discharge, gynecomastia, cardiovascular symptoms, and a history of cancer, anxiety, or depression. Urinalysis is negative, PHQ-9 score is four, and GAD-7 is two.
The patient denies experiencing fever, chills, weight loss, night sweats, blurry vision, hearing loss, sore throat, swollen lymph nodes, chest pain, leg swelling, cough, shortness of breath, nausea, vomiting, or diarrhea.
Denies dysuria, nocturia, hematuria, or urinary frequency, denies muscle pain or joint swelling
Syncope, weakness, or lightheadedness
No rush or lesion noted
Denies polyuria, polydipsia, polyphagia, or heat or cold. The nurse denies easy bruising or bleeding, and denies recent itching or high blood pressure.
Patient allergies: lisinopril reaction, angioedema
Thiazide reaction, hives, wheezing.
Patient medical history, hypertension, diagnosed four years ago, type 2 diabetes diagnosed two years ago, overweight, BMI
Medication: amlodipine PO 5 mg, glucophage 100 mg PO BID
Preventive health
The annual check was last visit eight months ago
The dental biannual visit was three months ago
Vision, sees an ophthalmologist annually, and wears contact lenses
Colonoscopy completed three years ago, no Abdulmalik
Immunization, all vaccinations up-to-date, including COVID and flu
Family history
Mother, 76 years: type diabetes, osteoporosis, overweight
Father, 77 years: hypertension, hyperlipidemia, overweight
Siblings: brother, 54 years old, hypertension, type 2 diabetes
Children: twin son, 22 years old, no health problems
Grandparents unknown
Social history
Non-smoker
Drink socially. 1-3 times per month, consume 1-2 beers.
Nice trucks
Diet, a low-carbohydrate and low-sodium diet
Exercise 2 to 3 times per week, no problem, fall stay this week
Stressors work and children who are recently moving out of the house
Living situation: lives with a spouse, children, and has recently moved out of the house
Supporting system, spouse, and brother
Finances deny problems
Denies exposure safety, we are seatbelt life planning, has a living room
sexual history: heterosexual, in a monogamous relationship with spouse
Physical exam height 72 inches, weight 202, BMI 27.4 AOx4
Blood pressure left 128/76, right 128/76, regular intensive for pressure, normal temp 36.9, oral pulse 78 BPM, read the regular strength, normal respiration 18, rhythm regular, effort unlabored, SPO 100 % room air
General
Alert and oriented, appropriate attention address, overweight body habitus
Normal eye, Perella regular funduscopic exam
Normal cardiovascular, regular rate, no murmurs, no friction, no swelling, bilateral lower extremities, refill less than two seconds, femoral and pedal pulses +2 and symmetric bilaterally.
Regular respiratory effort is observed without the use of accessory muscles, with clear breath sounds bilaterally.
Abdomen normal, active bowel sounds soft, no distension, and no tenderness to palpation
Neurologic bilateral lower extremity sensation in
Genitourinary/ rectal
Inguinal region: Nodes are mobile, nontender, pea-sized, and soft bilaterally.
Penis exam: circumcised penis without rash, lesion, or discharge at glance or shaft. Scrotum and perineum without rash, erythema, swelling, or visible masses. Testes descended bilaterally.
Nontender at glance and shaft, no induration or curvature at shaft. IIEF-5 score 17 mild
Scrotum exam: scrotum nontender palpation. Epididymides and spermatic cords without tenderness or nodules. Testes elevate with touch to the inner thigh bilaterally. No protrusion or both power people bilaterally wet and without forced cough and valsalva
Rectal exam: tone intact, no visible fissure, induration, allusion. No masses, tenderness, lesions, or hemorrhoids noted. The prostate is walnut-sized, symmetrical, nontender without nodules or bugginess upon palpation.
Psychiatric PHQ-9 and GAD-2 scores reviewed. Good eye contact, mood, and attention to detail. No slowed or rapid speech
Skin: No gynecomastia, masses, or tenderness
Screening performed at one patient intake Today
UrinalysisUA
Color, yellow, clarity, clear order, not slightly nutty
PH 6.0 protein zero specific gravity 1.010. Leukocyte esterase Negative
Nitrates 0
Ketones Negative
Bilirubin negative
Blood negative
urobilinogen 0.2
Glucose, urine negative
Identify 3-5 possible conditions
1-adjustment dis
2-Deny prostatic hyperplasia
3-Erectile dysfunction disorder
4-Hypothyroidism
Diagnosis
Erectile dysfunction
Diagnostic test
CBC, CMP, lipid panel, HbA1C, PSA, testosterone, bloodwork, TSH
Addressing a sound scrotal Doppler is not required
Result CBC, CMP, HBA1c , lipid panel , normal wang
PSA 0.6 Normal
Testasteurorne normal
TSH normal
Teacher Instruction::
This week’s focus is on genitourinary (GU) conditions, which commonly affect adults across the lifespan. Urinary frequency, for example, can result from a variety of conditions such as diabetes, urinary tract infections, benign prostatic hyperplasia, kidney infections, or even prostate cancer. Many of these conditions have serious implications and require a thorough patient evaluation. As an advanced practice nurse, it is essential to carefully assess a patient’s personal, medical, and family history before determining the most appropriate physical exams and diagnostic testing.
While your readings and course materials this week emphasize GU conditions, the i-Human case assignment is designed to reinforce your understanding of gastrointestinal (GI) conditions covered in Week 6. This intentional sequencing allows you to revisit and apply the GI concepts recently studied while continuing to build on new material related to GU.
For this Case Study Assignment, you will analyze an i-Human simulation of an adult patient presenting with a GI condition. Based on the case details, you will formulate a differential diagnosis, evaluate treatment options, and create an appropriate evidence-based treatment plan.
Resourcces:
- Be sure to review this week’s Learning Resources on genitourinary (GU) conditions, as you are still responsible for understanding and applying this content.
- Also refer back to the Week 6 Learning Resources on gastrointestinal (GI) conditions – they will be especially helpful for completing this week’s i-Human case study.
- Access i-Human from this week’s Learning Resources and review the assigned case study.
- Analyze the provided patient history, physical exam findings, and diagnostic test results to support clinical decision-making.
- As you interact with this week’s i-Human patient, complete the assigned case study. For guidance on using i-Human, refer to the i-Human Graduate Programs Help link within the i-Human platform.
Assignment Requirements:
Using the Management Plan Template provided in the learning resources, complete the following components:
1. Problem Statement
- Write a complete problem statement. Present the patient as you would to your preceptor, including subjective and objective findings.
2. Primary Diagnosis with Coding
- Identify the primary diagnosis with the corresponding ICD-10 code.
- Provide a rationale for the primary diagnosis.
- Include CPT codes for the office visit, preventive exam, and any procedures (e.g., vaccine, lab draw, ear lavage) performed during the visit.
3. Evidence-Based Guidelines
- Identify the clinical practice guidelines used to develop the primary diagnosis.
4. Differential Diagnoses
- List 3–5 differential diagnoses (distinct from the primary diagnosis).
- Provide a rationale for each diagnosis.
5. Management Plan
- Include prescribed and over-the-counter medications with drug name, dosage, route, and patient education.
- Detail nonpharmacological treatments and supportive care.
- Specify any required ancillary tests (e.g., ECG, spirometry, X-ray).
- List any necessary referrals (e.g., physical therapy, cardiology, hematology).
6. SDOH, Health Promotion, and Risk Factors
- Address social determinants of health (SDOH), including economic stability, education, healthcare access, neighborhood and environment, and social/community context.
- Outline health promotion strategies, including age-appropriate preventive screenings and immunizations.
- Discuss risk factors related to the primary diagnosis.
7. Patient Education
- Provide comprehensive patient education relevant to the current health visit.
8. Follow-Up
- Include the timeframe for the next visit and specific symptoms that would prompt an earlier return.
9. References
- Use a minimum of three scholarly references from the past five years.
Ensure that all responses are clear, evidence-based, and align with the rubric expectations. Submit the completed assignment in the required format and refer to the Management Plan Template for structure and guidance.