Toronto Notes

Patient Name: John Smith; Age: 62; Gender: Male; Chief Complaint: Difficulty urinating

You are a medical student doing a clinical rotation in the urology department. John Smith, a 62-year-old male, presents to the clinic with complaints of difficulty urinating for the past few weeks. Take a focused history of his complaint and perform a physical examination.

Your tasks:

1. Greet the patient appropriately and introduce yourself.
2. Take a focused history from the patient, including the following:
   • Onset, duration, and progression of symptoms
   • Description of the urinary difficulties (hesitancy, weak stream, intermittency, straining, etc.)
   • Associated symptoms (pain, urgency, frequency, hematuria, etc.)
   • Past medical/surgical history
   • Medications
   • Lifestyle factors (smoking, alcohol use, etc.)
3. Perform a focused physical examination, including:
   • General appearance
   • Abdominal examination
   • Digital rectal examination (if appropriate)
4. Based on the history and physical examination findings, develop a differential diagnosis.
5. Explain your clinical reasoning and formulate an initial management plan.
6. Provide patient education and counseling regarding the condition and next steps.

Case Script:

• History of Present Illness (HPI):
• Onset: Gradual onset over the past 3-4 weeks
• Symptoms:
• Hesitancy in starting the urinary stream
• Weak and intermittent urinary stream
• Straining to urinate
• Sensation of incomplete bladder emptying
• Nocturia (waking up 2-3 times per night to urinate)
• No pain or burning during urination
• No hematuria (blood in urine)
• No fever or chills
• Past Medical History:
• Hypertension (well-controlled with medication)
• Hyperlipidemia (well-controlled with medication)
• Appendectomy (age 25)
• Family History:
• Father had prostate cancer (diagnosed at age 70)
• Mother had breast cancer (diagnosed at age 65)
• Medications:
• Lisinopril 10 mg once daily (for hypertension)
• Atorvastatin 20 mg once daily (for hyperlipidemia)
• Social History:
• Married, lives with wife
• Retired accountant
• No current tobacco use (quit smoking 15 years ago)
• Occasional alcohol consumption (1-2 drinks per week)
• Habits:
• Diet: Generally balanced diet, not excessively high in fat or salt
• Exercise: Walks 30 minutes daily, no other regular exercise routine
• Sleep: Adequate, except for nocturia interrupting sleep
• Additional Information (if prompted):
• No history of urinary tract infections or kidney stones
• No recent trauma or surgeries
• No unexplained weight loss or appetite changes
• No neurological symptoms (back pain, leg weakness, etc.)