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You are a Foundation doctor working in GP. Mr Ant Erior is a 72-year-old man, presenting to your surgery with problems with urination

Please take a history from Ant and undertake an appropriate examination. You will then be asked to discuss the case with the examiner.  

You are Ant Erior, a 72 year old gentlemen who’s come to you GP, really annoyed about the fact that you can’t wee like you used to be able to. You’ve heard something from your friend about a tablet they got which helped loads so you’re hoping to get that.

HPC: You can’t remember the last time you slept through the night without having to get up to go the bathroom, getting up 3 or 4 times a night. You’ve tried avoiding drinking nothing a few hours before bed and cut out caffeine but that’s just made you more tired than you normally have been for the last few months. The problems are continuing during the day as well, where you just have to keep on going because your bladder just doesn’t feel empty. You’ve mapped out the nearest toilets when you go shopping in case you wet yourself (though you haven’t done so yet). It’s really annoying because you can’t take your grandchildren to the park for very long without having to find a bush or something similar. They’re the cutest kids, Mary is 4, just started nursery. She’s not happy at the moment as she’s just got a little brother.

You’ve also noticed a weaker urine stream and having to push yourself to get started to urinate. You also get a bit of a dribble when you’re finished urinated. Luckily, dark trousers can hide “dot of shame.” You haven’t noticed any blood in your urine or pain when urinating. You’re using this great pill for getting an erection and you’ve not noted any blood or pain when ejaculating or having sex. You’ve also noticed a bit of constipation and this nagging pain in your back (though you think it might be arthritis or something of the like). You’ve noticed your trousers feel a bit looser as well but you think it might be after all the running around after Mary.

PMH: You got told a couple of years ago you’ve got diabetes and you need to cut down on sugar in your tea and stuff. They didn’t say anything about biscuits though! Turns out they count as well so they’ve put me on a tablet for that. They also said yourblood pressure is a wee bit high with your cholesterol, so they’ve put youon stuff for that. You haven’t had any operations.

DH: Metformin 500mg BD Amlodipine 10mg OD Atorvastatin 40mg OD Sildenafil 50mg PRN Ibuprofen 200mg PRN



Your brother had appendix removed when he was 10 if that counts of anything?

SH: Retired draughtsman, used to work in mining and with other parts of industry. You currently live with the wife and a 3 year old Border Collie called Florrie. You’d usually have a can of beer at night but you’ve cut down to see if it’ll help with the urinating, you still have a few pints on a weekend though. You quit smoking about 5 years ago when you heard about Mary coming along. Before then, you were smoking about 10 a day for as long as you can remember.

ICE: You’re not really sure what it is, probably just growing old. You’re worried that if it keeps on getting worse, you’re going to have a proper accident one day and really embarrass yourself. You’re really hoping for a pill or something so you can get decent night sleep when you don’t have to get up to wee the whole bloody time. You might be able to shake of some of this tiredness if you did.

Please observe the student take a relevant history and examination from this gentleman, focussing on his urinary symptoms but also including red flag symptoms such as weight loss and bone pain. The most relevant examination in this case would be a PR exam which would find a firm, slightly enlarged prostate with an irregular nodule on one of the lobes. If an abdominal exam is done (which may possibly find a palpable bladder), PR must be mentioned by the candidate.

A good differential diagnosis may sound like this:

“My main differential in this gentleman would be likely be due to the prostate, more specifically prostate cancer. This is due to the red flags of bone pain and weight loss in conjunction with his symptoms of incomplete voiding, hesitancy and nocturia. However, these symptoms can also be seen in the BPH (benign prostatic hyperplasia) but patients with BPH do not have the red flag symptoms.”

Possible points of questioning can include:

• Investigations of prostate Ca including the use of PSA • Treatment of prostate cancer in localised and metastatic disease. • Treatment of BPH • The role of scoring systems (Gleason) in relation to prognosis of disease • The role of screening of PSA and rules for screening to be effective