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Case study A 68-year-old male presents to your clinic today. He complains of a cough for the last two (2) months that will not go away. He also complains of frequent urination for the last four (4) months. Past medical history only includes hypertension diagnosed five years ago, treated with hydrochlorothiazide. He does not know his family history since he was adopted. He has smoked ½ pack of cigarettes daily for the last 40 years.
DISCUSSION POST Reply to Marie
The case discusses a 68-year-old man with a persistent cough and frequent urine. We’ll review the preliminary and conclusive findings and lay out a detailed treatment strategy, including medical procedures and prescription drugs.
Differential Diagnoses
The patient’s frequent urination and chronic cough could be signs of several underlying diseases. The following differential diagnoses have to be taken into consideration in light of the facts provided:
COPD: Given the patient’s extensive smoking history, COPD, a common respiratory ailment characterized by emphysema and chronic bronchitis, maybe a possible diagnosis (Agarwal et al., 2022).
Chronic Bronchitis: This disorder causes the bronchial tubes to become inflamed and overproduce mucus, which results in a persistent cough. Chronic bronchitis is another possible cause of the persistent cough.
Prostate Issues: Males over 50 may experience frequent urination due to prostatitis, an inflammation of the prostate gland, or prostate hypertrophy (Ng & Baradhi, 2022).
Diabetes Mellitus: Frequent urination is also a symptom of diabetes, particularly type 2 diabetes mellitus, which is more prevalent in older people.
UTI : Older persons are more likely to get UTIs, which might make them urinate more frequently.
Final Diagnosis
The eventual diagnosis for this patient is likely to be COPD and Benign Prostatic Hyperplasia (BPH), following a comprehensive physical examination and pertinent diagnostic testing (Agarwal et al., 2022).
Plan of Care
Management of COPD
Lifestyle Modifications: Tell the patient to stop smoking immediately to prevent their lungs from worsening.
Bronchodilators: To improve lung function and lessen symptoms, prescribe long-acting bronchodilators such as tiotropium and short-acting bronchodilators like albuterol (Agarwal et al., 2022).
Inhaled Corticosteroids: Consider prescribing inhaled corticosteroids (e.g., fluticasone) to reduce airway inflammation and exacerbations.
Pulmonary Rehabilitation: Refer the patient to a pulmonary rehabilitation program to improve exercise tolerance and overall quality of life (Agarwal et al., 2022).
Vaccinations: Administer influenza and pneumococcal vaccinations to reduce the risk of respiratory infections.
Management of BPH
Alpha-Blockers: Prescribe alpha-blockers (e.g., tamsulosin) to relax the smooth muscles of the prostate, relieving urinary symptoms (Ng & Baradhi, 2022).
5-Alpha Reductase Inhibitors: Consider prescribing 5-alpha reductase inhibitors (e.g., finasteride) to shrink the prostate gland and improve urinary flow.
Monitoring: Schedule regular follow-ups to monitor the progression of BPH and adjust medications as needed (Ng & Baradhi, 2022).
Diagnostic Tests
The health care provider need to perform the following test. Perform Pulmonary Function Test to assess lung function and confirm the diagnosis of COPD (Agarwal et al., 2022). Conduct a chest X-ray to evaluate the presence of lung abnormalities and rule out other lung conditions. Measure Prostate-Specific Antigen levels test to screen for prostate cancer and assess the severity of BPH (Ng & Baradhi, 2022). Lastly, perform a urinalysis to check for signs of infection or other urinary abnormalities.
Medications
Albuterol: Short-acting bronchodilator for relieving acute bronchospasm.
Tiotropium: Long-acting bronchodilator to improve lung function and reduce COPD symptoms.
Fluticasone: Inhaled corticosteroid to reduce airway inflammation in COPD (Agarwal et al., 2022).
Tamsulosin: Alpha-blocker for alleviating urinary symptoms associated with BPH.
Finasteride: 5-alpha reductase inhibitor to manage BPH and improve urinary flow (Ng & Baradhi, 2022).
In conclusion, the 68-year-old male patient likely suffers from COPD and BPH. The comprehensive care plan includes interventions for managing COPD and BPH, regular follow-ups, and lifestyle improvements to enhance the patient’s quality of life and overall health.