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You are an F2 starting your GP rotation, the next patient to see in your busy clinic is Mr Lowfenack who is a 72yr old gentleman presenting with some problems passing urine. He is a has COPD, HTN and is due a review of his blood sugar levels. He has a known intolerance to statins.

Please take a history from this gentleman and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Mr Richard Lowfenack, (you prefer to be called Dick though) a retired plumber from South Shields. You’ve been having a bit of an embarrassing problem recently, and after a lot of nagging from the wife you’ve come to see the doctor. You’re not convinced there’s much they’ll be able to do, but it couldn’t hurt to see!

HPC You have been getting up to go to the loo 2 to 3 times every night for the last couple of weeks. You feel that you’re now spending more time standing over the loo then you do in bed. You’re so exhausted from all this you’ve taken to sitting down sometimes as you find it easier. If directly asked, you have noticed that the stream is a bit stop start, and sometimes you’ve dribbled a bit afterwards – even if you’ve given everything a good shake. There’s no pain or anything like that, and the colour doesn’t seem any different. It started very gradually and has probably been getting a bit worse, but its hard to tell. To be honest, its probably your age getting to you, but you’re just worn out from it and are getting fed up with the whole thing. Apart from that things with your health are alright. Before you ask, your chest is fine, and yes you have managed to quite the cigarettes. That’s all your doctors ever seem to be interested in these days! Your appetite is fine, you haven’t lost any weight. There’s been absolutely no problems with your bowel thank you very much.

ICE As you said, you reckon its just one of things with your age, but you thought you should just get in checked out in case there was something you could do to help. You’re not worried about anything much, just that its not going to get better and there won’t be anything you doctors can do to help.

PMH You have that COPD, which everyone has always said is due to the cigarettes. You don’t know though, you don’t feel much different, and if you’re being honest your breathing felt much worse when you stopped, although that does seem to have settled now. You’ve got high blood pressure you think, although it seems to be alright now you’re on the tablets. You’re sugars have been a little high last few times, and your regular GP said you would need to lose a bit of weight to improve them. Apart from that you’re normally fit and well

Drugs and allergies You take Ramipril 10 once a day, your blue and brown inhaler. Your normal GP has tried you on a bunch of those cholesterol tablets, but they all gave you leg cramps so you couldn’t stand them. Not sure they were doing much for you anyway. You’re not allergic to anything else that you know of.

SH You a retired plumber, you stopped about 10yrs ago. You miss it a bit if you’re honest, you don’t like sitting around doing nothing, and it was great to meet people. You live with your wife, in a house just around the corner from here. You used to smoke 25-30 a day until just before after you retired. You haven’t touched one for the last 5 years, despite all the temptation. You don’t drink much now you’ve retired, maybe 2-3 pints on the weekend. Used to be more like 2-3 a night when you were younger! You’re fine with walking, don’t need a stick or anything, and you and the wife cope just fine on your own.

FH Your older brother died from a heart attack 10 years ago, just after you retired. Your dad always had heart trouble as well. You’re pretty sure they had high sugars as well.

The student should take a detailed history of the patient’s presenting complaint sensitively dealing with his concerns. They should perform an abdominal exam. It is very important that they mention they would perform a digital rectal examination as part of the examination (although obviously they are not expected to actually do this).

They should mention BPH in their differentials, and prostate cancer should be something the student considers. It would not be unreasonable to consider diabetes as a differential due to the history of elevated blood sugars and urinary symptoms. Examples for discussion may include:

• Initial investigations for this man’s problems • Tests to help differentiate BPH from prostate cancer • What would you be likely to feel on DRE (what would make you think its was BPH or cancer) • Management of BPH, including medical and surgical options • Possible complications associated with surgical management (particularly TURP) • PSA testing, when would it be appropriate and what are its limitations