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 doctor working in family medicine. Your next patient is a 65-year-old gentleman, Logan Freeman, presenting with groin pain. Please take a history and perform an appropriate examination.
Patient History:
Logan Freeman, a 65-year-old gentleman, retired.
You are coming in today as you have been experiencing worsening left groin pain in the last two days, which started quite quickly. You describe the pain as a constant burning sensation. It is located deep down the groin and localised there. You rate the pain 6/10. The pain is worsened when you open your bowels and is relieved by taking ibuprofen.
You also have pain while urinating with increased urinary frequency since the past week. You do not have urine retention, but the stream has been slow. You do not use a urinary catheter. No blood from urine currently (settled from recent prostate biopsy last week).
You are currently experiencing unexplained weight loss and night sweats - which you went to see a urologist for possible prostate cancer. You have been told that you have a raised prostate marker. You will soon find out the results from the recent prostate biopsy they did last week. You can't remember if you were given prophylactic antibiotics.
You feel hot and cold, but you haven't taken a temperature yet, so you are unsure if you have a fever. You feel tired. You have muscle aches all around the body, and you do not feel great at all!
You are currently happily married for 30+ years. Your last sexual intercourse was a long time ago - God knows! You are slightly constipated, but you are opening your bowel without any major issues.
No rashes. No SOB. No diarrhoea. No penile discharge. No issues with the testicles.
Ideas, Concerns, Expectations:
You think this might be related to your prostate. You are worried that you have prostate cancer and hope the cancer is not spreading. You would like to get treatment as soon as possible.
Past Medical History:
Benign prostatic hyperplasia
Hypercholesterolemia
Transrectal prostatic biopsy for suspected prostate cancer one week ago
Drug History:
Tamsulosin
Atorvastatin
NKDA
Family History:
Nil
Social History:
You stopped smoking a month ago, as you have been told to quit by the urologist - but you used to smoke ten cigarettes/per day for 20+ years.
You drink 5-10 units of alcohol per week.
You live with your wife in a bungalow.
You are managing well independently at home.
You are retired, but you used to work as a voice actor.
Examination Findings:
Digital rectal exam: warm, tender and enlarged prostate; a small nodular mass can be felt at the left side of the prostate gland.
Testicular / penis exam normal.
Abdominal examination normal.
No renal angle tenderness.
No obvious inguinal lymphadenopathy
Differentials:
Acute prostatitis (bacterial/ non-bacterial) - likely due to an infective cause from a recent prostatic biopsy
Cystitis / UTI
Prostate pain syndrome
Urinary tract stones
Prostatic abscess
Underlying prostate malignancy
Investigations:
Observations
Urine dipstick testing - infection
Urine MC&S
Chlamydia and gonorrhoea NAAT testing
Consider Bloods: FBC, U&Es, CRP, Blood culture + other baseline bloods
Consider transrectal ultrasound to rule out prostatic abscess/ cysts / seminal vesicle obstruction
Consider the 4-glass / 2-glass test in chronic prostatitis
PSA should have been done before the investigation for prostatic cancer. Prostate biopsy in the past six weeks can raise PSA levels and affect results. Other factors that raise PSA level is vigorous exercise, ejaculation, prostate stimulation in DRE...etc.
Management: