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You are an F2 in your GP placement, Mr Ardium has come today to talk about a ‘personal problem’. The notes suggest that Mr Ardium is normally fit and well, but has been to the surgery a couple of times in the last month for antibiotics for urinary tract infections. He doesn’t seem to be taking any regular medication.

Please take a focussed history of his presenting complaint and sensitively deal with his concerns. Perform an examination as appropriate. You will then be asked to discuss the case with the examiner.

You are Mike Ardium, a 65yr old retired school teacher. You are normally very fit and well, and pride yourself on the fact that you are still in as good a shape as when you were 30. In fact this year will be the 10th time you run the London Marathon. That however, seems to have changed a bit over the last few months, you’ve been having real trouble with urinary tract infections and have had to see the doctor a couple of time for antibiotics. You find the whole thing very embarrassing, especially when they ask such personal questions, so you might be a bit reluctant to answer personal questions directly. What makes it worse is that so many of the doctors you see these days are younger than your own children! You just hope you can see your regular GP for once, you don’t have to spell everything out to him, and he’s great and just giving a bit of reassurance or a couple of antibiotics if really needed. He never asks for the gory details and it spares both of you a great deal of embarrassment.

HPC To be honest, its very embarrassing, but you thought it was important after you saw those adverts on TV so that’s why you’ve come today. Over the weekend you noticed that your water looked, well, as if there was a bit of blood in it. There wasn’t loads of it, but you noticed it when you went to flush the loo. Its been a bit sore passing water for the last few weeks, and you had some antibiotics from your regular GP, but that didn’t really seem to clear it this time. You had hoped it would settle over time, but you’ve never seen blood before, and this has got you a bit worried. Over the past few months, maybe even just over a year now you think about it, your waterworks have been giving you a lot of trouble. It started off with just struggling to start passing water. It got slowly worse, and you you’re up all through the night trying to get a bit of a trickle out. You’ve had episodes of burning when you pass water, which clears up with the antibiotics the GP gives you. Apart from that you’re feeling fine – you’re very fit for you age. If asked directly - you haven’t been feeling tired, your weight is very well controlled and you’re eating a very good diet and your appetite is much the same as ever. The only other thing that’s been a problem, its only mild mind you, is a bit of lower back pain that just isn’t settling. Its nothing to worry about, probably just twinged something when doing exercise. If asked about sexual function you will be very uncomfortable, and ask the doctor exactly what business of theirs that is. But if they press you, and ask in a sensitive manner, you would tell them that over the last couple of weeks when you’ve ejaculated its been sore, and you have noticed a bit of a blood streak on one or two occasions. You haven’t had any risky sexual practices, and have only had one sexual partner for the last 30 years.

ICE You think its just the water infection causing a bit of blood, and that it might be a worse infection this time or taking longer to clear the system. But since you saw those adverts on TV, you did a bit of reading on the internet, and now you’re worried you might have cancer. You know that sounds a bit silly and after some reassurance like you normally get from your doctor, and maybe a blood test or something like that to 100% prove you don’t have it so you can put your mind to rest.

PMH Water infections, probably about 4 that you’ve had to go get some antibiotics for from the GP in the last few months Apart from that very fit and well. You had you BP and sugars checked recently and were told they were that of a much younger man.

SH Smoking is your one unhealthy guilty pleasure. You only smoke maybe 5 a day now, but when you were younger you had up to 20 a day No alcohol, haven’t had any for the past 10 years Live with your wife, and the dogs, you’re very independent and are enjoying your retirement so far. You retired about 5 years ago, you used to be a geography teacher at the nearby secondary school.

Drugs and allergies No prescribed medications. You have been using Paracetamol from the supermarket to help with the back pain recently, and you do buy protein supplements and vitamin tablets You’re not allergic to anything as far as you know

FH There’s been a bit of heart trouble in your family, one of the reasons you try to keep yourself so fit. Apart from that nothing seems to run in the family. No history of cancers or diabetes. 

The student should take a detailed history of the patient’s presenting complaint sensitively dealing with his concerns. Good students will illicit Mr Ardiums problems when he ejaculates in a sensitive manner, explain the importance of such questions to the patient. 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 prostate cancer in their differentials. It would not be unreasonable to consider bladder cancer and BPH as well.

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 prostate cancer, 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 • Risk factors for prostate cancer • Common areas for metastases of prostate cancer