Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient is 70-year-old Jack Deshawn, who came in for a routine check-up. He has a past medical history of hypertension, for which he is taking amlodipine. Please take a general history and perform a relevant examination.
Patient History:
Jack Deshawn, a 70-year-old male, retired.
(The purpose of this interview is for you to discuss your urological complaint. You spend the first few minutes discussing blood pressure, but after a few minutes of building rapport, you should interject to discuss your urinary problems)
You're here for your routine check-up, and you have to say things have been going great! Your blood pressure has been fine, with your average readings at about 145/90. The lovely lady or nurse who took your blood pressure just before you came in here was very happy with your BP when she checked it – it was a good 135/80.
You haven't had any problems with your vision and haven't had to go to the hospital for anything. Thankfully no heart attacks or strokes!
(You cut off the doctor) – you just remembered that your previous doctor said blood pressure can affect your kidneys, right?
Well, you've noticed some kidney problems for the past month. You've been visiting the toilet more often, even at night sometimes. You often get a sudden urge to go to the toilet or feel like you might wee yourself, but you haven't had any incontinence. You also sweat a lot, especially at night.
There's no pain when passing urine, though you have to strain. You can sometimes see blood in your urine. You don't have any tummy pain and no fever. Your stream is okay, you suppose (you don’t properly understand what this means), and you don’t get any dribbling.
When the doctor mentions it, you notice that you're buckling your belt a bit tighter, possibly from losing some weight. You don't have any balances at home to weigh yourself anyways. If asked directly, mention you have had some focal lower back pain for the past month.
Ideas, Concerns, Expectations:
You're quite pleased to be here and think you're doing fine. The weeing problem is somewhat of a nuisance, but you remember your father having similar problems when he was older, so this must be a part of growing older, like those back pains. You'd like to be on your jolly way and head back home in time for the game!
Past Medical History:
High blood pressure
Drug History:
Amlodipine 10mg daily
NKDA
Family History:
Your father died of cancer at the age of 60 - you don't remember what it is.
Social History:
You live at home with your son and are frequently visited by your three daughters.
You're an independent man who always remembers to take your pills at the right time without anyone's help.
You've smoked 10 cigarettes daily since you were 15 but don't drink alcohol.
You hate the taste of coffee but drink a cup of tea every day after meals.
Examination Findings:
No abdominal or suprapubic tenderness, masses or organomegaly.
If mentions DRE = asymmetric, nodular prostate with obliteration of the median sulcus.
Differentials:
Prostatic cancer (elderly man with FH of ?prostate Ca associated with weight loss and back pain)
Prostatitis (typical history involves pelvic pain, fever and dysuria with tender enlarged prostate)
To rule out UTI
Bladder cancer (typically haematuria with normal prostate)
Detrusor weakness/instability
Neurological conditions e.g. MS, spinal cord injury
Investigations:
Bedside:
Urine dipstick (infection, blood)
Patient voiding diary (quantify severity)
International Prostate Symptom Score (IPSS) to assess the severity
Bloods:
PSA (non-specific, though very elevated levels e.g. x10 are highly indicative of cancer)
U&E (associated renal impairment)
LFT (raised ALP may indicate metastasis, baseline before hormone therapy)
Imaging/ Special Test:
Multiparametric MRI (usually first line, results reported on 1-5 Likert scale)
Transrectal US-guided or transperineal biopsy (confirms the diagnosis and Gleason grading)
Technetium-99 bone scan (locate bony metastases)
Bladder USS and post-void residual volume
Flow rate measurement & urodynamic studies
Management: