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-=-=-=-=-=> 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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