History of Present Illness
Max Wellington is a 59 y/o male with a history of diabetes mellitus type two on oral meds, frequent urinary tract infections and hypertension. He presents to the office today with c/o of dribbling, frequency hesitancy and also now some erectile dysfunction which is more apparent due to the fact that he is in a new relationship.
Chief Complaint
“I am up 4-5 times at night having to pee. I am dribbling urine and sometimes I do not make it to the bathroom in time. It is also sometimes hard to get going once I get to the bathroom. I recently met a very nice woman and we are in a relationship, but I am finding it increasingly difficult to be intimate with her. Being up all night going to the bathroom and then going to the bathroom on myself is ruining my love life!â€
Past Surgical History
Appendectomy age 14
Medications
Metformin 500mg po BID, Toprol XL 50mg po daily, Terazosin 10mg po daily.
Allergies
Seasonal allergies i.e. leaves and pollen, worse in the spring. No known drug or food allergies.
Medical History
Hypertension (HTN), Diabetes Mellitus Type II, frequent Urinary Tract Infections
Family History
He is an only child. His mother is living at age 85 with HTN, HLD, CAD, DM II and his father is deceased at age 78 from an MI.
Social History
Divorced, in a new relationship with one female partner for the last 6mo. Has 2 adult children, one son and one daughter, both in good health. Denies heavy ETOH use, reports a glass of wine 1-2 times per week. Previous smoker, 1ppd for 20 years, quit in 2000. He is still working full time as a car salesman.
General
Denies recent fever, weight loss. Does admit to feeling fatigued because he is up so many times at night. Sitting comfortably in exam table, well nourished, in no acute distress.
