| | 37 Case 37 scenario ( difficulty urination)
Doorway information about patient
. The patient is a 65-year-old man who comes to the office due to difficulty with urination
Vital signs
. Temperature : 37.2’C(99F)
. Blood pressure ; 130/80 mmHg
. Pulse ; 92/min
. Respirations : 16/min
Basic differential diagnosis
. Benign prostate hyperplasia
. Prostatitis
. UTI / cystitis
. Carcinoma of the prostate
. Stone in the urinary tract (obstructive)
. Carcinoma of the bladder
. Neurologic dysfunction
. Drug-induced bladder dysfunction
—————
Case 37 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
History of present illness
. Onset of symptoms 2 months ago
. Difficulty initiating urine stream with decreased flow , straining with urination , sensation of incomplete emptying , and increased urinary frequency
. Mild burning on urination and 1 episode of blood in the urine
. Getting up 5-6 times a night to urinate
. Asked doctor :” Do you think I have prostate cancer?”
Review of systems
. Decreased appetite with 4.5-kg (10-lb) weight loss over the last year
. No fever or chills
. No abdominal pain , diarrhea , or constipation
. No muscle weakness
. No recent trauma
Past medical / family / social history
. Diabetes mellitus for the past 10 years
. No surgeries or hospitalizations
. Medications : Metformin 500mg twice daily
. No drug allergies
. Father died of prostate cancer at age 75 , mother died of “kidney problems” at age 78 , sister is healthy
. Occupation : Accountant
. Married , lived with wife
. Tobacco : No
. Alcohol : 2 beers /day for last 35 years
. Recreational drugs : No
Physical examination
Abdomen :
. Non-tender, non-distended
. Normative bowel sounds
. No hepatosplenomegaly
. No CVA or suprapubic tenderness
Neurologic :
. Motor 5/5 throughout
. DTR 2+bilaterally
—————
Case 37 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the onset of symptoms and course over time
. Asked about difficulty initiating or maintaining urinary flow
. Asked bout the strength of flow
. Asked about intermittency (stopping and starting again while urinating), straining, and sensation of incomplete emptying
. Asked about the frequency or urination
. Asked about urgency
. Asked about nocturia
. Asked bout any burning sensations with urination
. Asked if any blood in the urine
. Asked about associated symptoms , especially :
- Abdominal pain
- Fever
- Weakness in legs
- Change in bowel movements
- Change in appetite or weight
- Back pain or trauma
Past medical /family/social history
. Asked about similar episode sin the past
. Asked about past medical issues(especially urinary or sexually transmitted infections), Surgeries , and hospitalizations
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco, alcohol , and recreational drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined abdomen (auscultation ,palpation)
. Examined back , including palpation/ percussion for ocstovertebral angle tenderness
. Tested lower extremity strength and reflexes
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Explained the need for rectal / prostate examination
Communication skills and professional conduct
. Knocked before entering the room
. Introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Benign prostate hyperplasia
. Urinary tract infection
. Prostatitis
. Prostatic carcinoma
. Bladder carcinoma
. Overflow incontinence
Diagnostic study/studies
. Rectal examination
. urinalysis andurine culture
. Serum BUN , Creatinine , glucose
. Hemoglobin A1c
. CBC with differential
. Prostate-specific antigen
—————
Case 37 clinical summary
Clinical Skills Evaluation
Case 37 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 95-yo man with 2 months of difficulty initiating urination , decreased urinary flow , nocturia , increase urinary frequency , and incomplete emptying of bladder
. 1 episode of hematuria
. Decreased appetite and 4.53kg(10-lb) weight loss over the past year.
ROS : No increased urinary urgency , abdominal pain, flank pain , fever , chills , diarrhea , constipation, leg weakness , or trauma
PMHx : Diarrhea for past 10 years
PSHx : None
Meds : Mptformin 500 mg twice a day
Allergies : None
FHx : Father died of prostate cancer ; motor died of kidney problems
SHx : No tobacco use l 2 beers daily for 35 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs: Temperature ,37.2;C(99F); blood pressure , 130/80 mmHg; pulse, 92/min; and respirations, 16/min
. Abdomen : Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness
. Neurologic : Motor 5/5 bilaterally , DTR 2+ bilaterally
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Benign prostate hyperplasia
History finding(s)
. Difficulty with urination
. Incomplete emptying of bladder
. Nocturia, decreased urinary flow
Physical examination finding(s)
. None
Diagnosis #2 : Prostate cancer
History finding(s)
. Family history of prostate cancer
.Decreased urinary flow, nocturia
. Weight loss
Physical examination finding(s)
. None
Diagnosis #3 : Bladder cancer
History finding(s)
. Gross hematuria
. Incomplete emptying of bladder
. Weight loss
Physical examination finding(s)
. None
Diagnostic studies
. Rectal examination
. Urinalysis with curse culture
. PSA
. Basic metabolic panel
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