Situation
The patient is Mr. G.K. Ackah. He complains of urinary retention and a headache “on and off” for a week.
Background
The support information is that patient was admitted through the emergency room yesterday. Since the admission, the patient’s vitals have been stable. Blood pressure was 142 over 86; the patient did not feel any pain but felt uncomfortable for some time.
The patient has a penicillin allergy and was immunized against influenza.
Past medical history includes hypertension (HTN). The patient does not wear glasses or use any hearing aid.
Assessment
The admitting physician, Dr. Montgomery, diagnosed the patient with Benign Prostatic Hyperplasia (BPH).
Recommendation
Dr. Montgomery recommends transurethral resection of the prostate (TURP) surgery for the patient. The patient has given oral consent to the surgery. In addition, the patient was informed about the purpose and the length of the surgery, the post-surgical care, and other details regarding the procedure. The patient has been NPO today.
Reference
Montgomery College. (2013). Intro to Cultural [PDF document]. Web.