Discussion Week 3: Describe your clinical experience for this week
Did you face any challenges, any success?
It was another very busy week in the community health clinic in West Perrine. The weather here in Miami has been very stormy and my assumption, was that less patients would arrive to the clinic. But indeed, the scheduled patients did arrive along with several walk-ins that are never turned away. My challenge this week was with a male patient who was obviously uncomfortable with me in the room. But having an established relationship with my preceptor for many years, the patient agreed to allow me to accompany them in the evaluation.
Describe the assessment of a patient.
S.) CC: “I am here for erectile dysfunction.” HPI: J.S. is a 61-year-old Cuban-American male who presented to the clinic with complaint of sexual dysfunction due to the inability to sustain a penile erection. He reports that for the last 5 years, he has noticed an inability to maintain an erection intermittently, but it was not bothersome until most recently. Six months ago, he reports committing to a relationship with his girlfriend and feels self-conscious and down, that he cannot perform sexually the way he used to. He states he was concerned that she is unsatisfied, and he feels embarrassed. PMH: J.S. reports a past medical history hypertension and tachycardia (2017), for which he takes lisinopril and atenolol. He also reports a history of hyperlipidemia (2012). FX: He reports a family history that is significant for paternal death at age 65 due to cardiovascular disease (CVD). His mother also passed away one year ago from respiratory complications related to Covid-19. SX: The patient reports that he is divorced and has two, healthy adult children. He admits to a 20-year, on and off again, smoking history (cigarettes) at work only (construction foreman), drinks ETOH socially 3-5 nights per weeks, and has caffeine daily. Sexual HX: Pt reports ED began 5 years ago but he attributed it to stress and lack of intimacy. He states he has never had an STI and experiences no pain with ejaculation. He reports that he is unsatisfied with his sexual performance and feels embarrassed. He has not tried any treatment for ED. Psychosocial: Pt. states he has a lot of stress with regard to his work and loss of his mother one year ago, but feels he is coping with the support of his daughters and girlfriend. He denies illicit drug use and denies any known allergies. His medications atenolol 25mg PO BID & lisinopril 20 mg daily (HTN), and atorvastin (hyperlipidemia). Health Maintenance: Pt. states his PSA screening and colonoscopy were normal one year ago. He is up to date with immunizations, including Covid-19 (Pfizer x2, 3/2021).
O.) VS were within normal limits for temperature, pulse, respiration, and pulse oximetry. BP was 139/80. BMI within normal limits for height and weight. Pain level 0/10. General: 61-year-old, Cuban-American male appears healthy and in no apparent distress. He is AAOx3, well groomed, and makes good eye contact. A focused physical exam was conducted. HEENT: Normocephalic. Clear, white sclera. PERRLA. Throat without swelling or erythema. Slightly raspy voice noted, no lesions noted. Neck: Trachea midline without enlargement or pain. Chest: No gynecomastia noted. No lesions or masses bilaterally. Pulmonary: Symmetrical chest rise, with lung sounds clear to auscultation. No cough. CV: S1 S2 noted with regular rate and rhythm. No gallops or murmurs. No edema noted in upper or lower extremities. GI: Abdomen slightly rounded, with good bowel sounds x4. No tenderness appreciated, and no enlargement of spleen or liver noted. GU: Uncircumcised penis without lesions or discharge. Testicles descended bilaterally, no atrophy. Cremasteric reflex positive. No evidence of palpable masses or inguinal hernias noted.
A.) Erectile dysfunction, hypertension, hyperlipidemia. Differential diagnosis includes testosterone deficiency, decreased libido, anorgasmia, diabetes mellitus (Cash & Glass, 2019).
P.) This patient’s plan begins with lifestyle modifications which include increased physical activity, limiting or cessation of alcohol consumption, and complete cessation of smoking. The patient was encouraged to improve his nutrition and seek healthier coping mechanism for his work-related stress. Pt. was also offered bereavement counseling referral in relation to the loss of his mother for which he has accepted.
According to Kennedy-Malone et al. (2019), diagnostic testing is not indicated specifically for drug-induced ED but performed to eliminate other possible causes of impotence. Diagnostics ordered for this patient included testing for total testosterone, free testosterone, TSH, lipid panel, serum prolactin, and diabetes screening (fasting glucose and hemoglobin A1c). Pt. was made aware that ED can also be a side effect of the medications he is taking for hypertension and tachycardia (Beta-blocker). He will be referred to his cardiologist for ECG monitoring of his cardiac status and possible substitution (or weaning) of his medication as well as clearance to take a PDE-5 inhibitor. Possible referral to urologist for further evaluation may be warranted in the future.
According to Cash & Glass (2019), first line drug therapy after lifestyle modification is with PDE-5 inhibitors which are shown to improve erections and successful intercourse with approximately 80% success rate. The patient was prescribed sildenafil citrate 25 mg PO to take on an empty stomach 30-60 minutes prior to sexual intercourse. Side effects were discussed with the patient and he is to continue his BP log and heart rate monitoring, as well as see his cardiologist. Pt. will follow up in 1-3 weeks to discuss effectiveness (and possible titration) and health status. Pt. was educated on emergency situations in which priapism that may last for more than 4 hours require emergent urologic attention (Hollier, 2018).
What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
It was very beneficial, as a female healthcare provider, to understand and empathize with our male patients who are experiencing erectile dysfunction (ED). It can be an uncomfortable situation for them as he stated he felt embarrassed and ashamed. ED is often accompanied by low self-esteem, performance anxiety, depression, stress, and effects on one’s quality of life. I learned there are tools to assist the practitioner in assessing sexual dysfunction like the Erectile Hardness Scale (EHS) and the International Index of Erectile Function (IIEF), to name just two, that help to open the conversation and guide our assessment and treatment plan.
Cash, J. C., & Glass, C. A. (2019). Adult-gerontology practice guidelines. Springer Publishing Company, Llc.
Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates.
Kennedy-Malone, L., Lori Martin Plank, & Evelyn Groenke Duffy. (2019). Advanced practice nursing in the care of older adults (2nd ed.). F.A. Davis Company.