CHIEF COMPLAINT: Urinary tract infection.
HISTORY OF PRESENT ILLNESS: The patient presents to the emergency department with a two-day history of dysuria, hematuria, and urinary retention. He has a history of enlarged prostate. He does take medications from his primary doctor for this. He also gets frequent urinary tract infections secondary to this. He states that this feels like a typical infection for him. He has had history of kidney stones in the past, however, he states he does not have any flank pain and states that this does not feel like a typical kidney stone episode for him. He has not had any fever. He otherwise has no other complaints.
PAST MEDICAL HISTORY: BPH as mentioned previously.
MEDICATIONS: Proscar and Cardura.
ALLERGIES: Bactrim and other sulfa drugs.
SOCIAL HISTORY: The patient does not smoke, use alcohol or illicit drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 136/76, pulse 80, respirations 18, temperature 99.2, and 02 sat 98% on room air.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.
RECTAL: Exam was refused by the patient.
GENITOURINARY: Exam was within normal limits with no evidence of any lesions or external infectious processes.
EMERGENCY DEPARTMENT COURSE: The patient was given Cipro 500 mg to take in the emergency department for probable cystitis. Urinalysis was done. It did show positive protein as well as blood. He did not have nitrites or leukocyte esterase present. He does have a regular doctor who he sees in followup on an outpatient basis. At this time, we decided that he should be treated with antibiotics because of the symptoms and history of prostatism. He was given Cipro 250 mg to take twice a day for a week for the cystitis. He should follow up with his regular doctor in a week or two.
DISCHARGE DIAGNOSIS: Acute cystitis.
PLAN:
1. He should take the medication as directed.
2. Follow up with his regular doctor.
DISPOSITION: The patient was discharged to home.
