S.M. is a 68-year-old male who is being seen at your clinic for routine health maintenance and health promotion. He reports that he has been feeling well and has no specific complaints, except for some trouble “emptying my bladder”. Vital signs at this visit are 148/88, 82, 16, 96.9F. He had lab work completed last week and the results are listed below. While obtaining your nursing history, you record no family history of cancer or genitourinary problems. S.M. reports frequency, urgency and nocturia X 4; he has a weak stream and has to sit to void. These symptoms have been progressive over the past 6 months. He reports he was diagnosed with a large prostate a number of years ago.
Lab Results:
Sodium 140 mEq/L
Potassium 4.2 mEq/L
Chloride 100 mEq/L
Bicarbonate 26 mEq/L
BUN 19 mq/dL
Creatinine 0.8 mq/dL
Glucose 94 mq/dL
RBC 5.2 million/mm3
WBC 7400 mm3
Hgb 15.2 g/dL
Hct 46%
Platelets 348,000/mm3
Prostate-specific antigen (PSA) 0.23ng/mL
Urinalysis WNL
Discussion Questions:
What can you tell S.M. about his lab work?
What is the significance of the PSA result?
Identify the categories of the health history that have been addressed and those for which additional data must be obtained.
Relate expected (normal) findings to those described for this patient and discuss any additional information that might be needed before a diagnosis can be made?
Based on the assessment data presented, what are the health issues? Provide rationale.
Discuss the developmental (physical, cognitive, psychosocial and behavioral), age, socioeconomic and cross-cultural considerations that should be considered during the gathering of subjective and objective data and the provision of health care for S.M.
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