History and Physical and Labs

History and Physical and Labs
CC: Routine check up
HPI: AH, a 52 year-old African American male in no apparent discomfort or distress, is
noted on routine exam to have a PSA of 7.0. Denies impotence.
PMH: PSA 3 years ago was 3.5 but no other problems.
FH: Father died of prostate cancer at age 63, mother lived to be 87, maternal grandfather
lived to be 101.
SH: tobacco – 50 pack years; Alcohol – 1drink a day: Drugs – none
Lives with wife and 3 children.
Physical Exam
VS: T= 98.6 HR=70 RR=12 BP= 120/80 O2 sat 100% on RA
General: AH is a well-nourished, well-developed gentleman.
HEENT: Pupils equal, round and reactive to light and accommodation, extra-ocular
muscles intact, oropharynx moist and pink with no exudates
Neck: No lymphadenopathy, no jugular venous distension, no thyromegaly, no bruits
Chest: Lungs were clear to auscultation bilateral.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2, no rubs/murmurs/gallops.
Abdomen: Nontender, nodistended, soft abdomen, no organomegaly. Positive bowel
Neuro: Alert & oriented x3; cranial nerves II-XII intact, sensation to light touch and
proprioception grossly intact on toes and fingers, range of motion of upper and lower
extremities is normal, muscular strength 5/5 in upper and lower extremities, 2+ Achilles,
patellar, biceps, triceps reflexes (0-4 scale; 2+ is normal), toes downgoing, finger-tonose intact, heel-to-shin intact, normal gait
Extremities: mild lower extremity edema
Rectal: mild prostatic enlargement, prostate smooth with no nodules
Lab Data:
PSA = 7.0 (prostate-specific angigen, 7.0 is elevated for a man of this age)
Ultrasound and biopsy:
TRUS (transrectal ultrasound) – hypoechoic lesion on the lateral aspect of the left
lobe of the prostate.
Path - 2 of 4 cores from left lobe of prostate show involvement with
adenocarcinoma. All 4 cores from the right lobe of prostate are negative for cancer.