Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.

Learning Goal: I’m working on a nursing question and need an explanation and answer to help me learn.

  • Discuss the Mr. Payne’s history that would be pertinent to his genitourinary problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.
  • Describe the physical exam and diagnostic tools to be used for Mr. Payne. Are there any additional you would have liked to be included that were not?
  • Please list 3 differential diagnoses for Mr. Payne and explain why you chose them. What was your final diagnosis and how did you make the determination?
  • What plan of care will Mr. Payne be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
  • Forty-five-year-old male truck driver complaining of two weeks of sharp, stabbing back pain after lifting a 10-lb. box. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed.
  • Vital signs:
    • Temperature is 37 °C (98.6 °F)
    • Pulse is 80 beats/minute
    • Respiratory rate is 12 breaths/minute
    • Blood pressure is 130/82 mmHg
    • Weight is 77 kgs (170 lbs)
    • Body Mass Index is 24 kg/m2

    Past Medical History: Diabetes, well-controlled. Hypertension, fair control. Hyperlipidemia, fair control.

  • Past Surgical History: None
  • Social History: Works as a truck driver, which involves lifting 9-16 kgs (20-35 lbs) 4 hours of the day, married with 2 daughters,
  • Habits: Smoked one pack per day for 20 years. Quit smoking two years ago, drinks one to two beers occasionally on the weekends, no history of IV drug use.
  • Medication:
    • Metformin 1000 mg PO twice daily
    • Glyburide 10 mg PO twice daily
    • Amlodipine 2.5 mg PO daily
    • Lisinopril 40 mg PO daily
    • Simvastatin 40 mg PO daily

    Allergies: No known drug allergies.

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