Chief complaint: 52-year-old African American male presented to the office with chief
complaint of voiding difficulty and pain.
HPI: “I been having
... [Show More] some dribbling and discomfort pain after peeing for some time now. I have
been going to the bathroom more often since I do not feel like I have finish peeing all the way.
The reason I am here today is because last night, I noticed a small amount of blood in my semen
after having intercourse with my wife. I did not want to come, but this is really scaring me and
my wife said this is not normal.”
Patient Medical History: Current treatment for diabetes, hyperlipidemia, hypertension, erectile
dysfunction
Childhood illnesses: Varicella, common cold
Patient surgical history: Hernia repair
Hospitalizations: None
Immunization: Up to date on all vaccinations
Allergies: NKDA
Current medications: Metformin 500 mg BID daily, Atorvastatin 20mg at bedtime, Amlodipine
10 mg daily and Cialis 10mg PRN.
Family History: Children are healthy. Mother has diabetes and cholesterol. Father has HTN,
BHP, and hyperlipidemia. Brother: BPH, PGM: Deceased unknown causes and PGF: erectile
dysfunction died at 73 from heart attack.
Lifestyle: In monogamous married relationship with his wife of 20 years. The patient works at
the local High school as a math teacher. Due to the COVID-19 quarantine, he has been working
from home, lives a sedentary lifestyle, increase his weight and food intakes.
PE: Height 5’11’, Weight 234 pounds
Vital signs: BP 151/94, Temp. 97.8, P 86, Oxygen sat 99% on room air.
General: African-America male. Alert, oriented, cooperative. Pt appears unease and changing
positions in chair every couple of minutes.
Skin: Skin warm, moist, intact. Skin color dark brown skin tone without cyanosis or pallor.
HEENT: Head norno-cephalic. Hair thin coarse hair with a bald circular spot on back of head.
Eyes: Sclera clear, conjunctive: white, PERRLA. EOMs intact with no AV nicking noted.
Nose: Nares patent without exudate. Sinuses non-tender to palpation. Nasal septum without [Show Less]