Urology

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.)

You are seeing Ms. Hamilton, a 64 year old man, for left sided back pain. She says it began three days ago and isn’t getting any better. Take a focused history of her complaint and perform a physical examination.

History

• Onset and duration of pain
• Progression of pain
• Location of pain (unilateral)
• Frequency of pain (intermittent)
• Quality of pain (sharp)
• Radiation (to abdomen and groin)
• Flank pain (yes)
• Changes in amount of urine
• Dysuria
• Urgency
• Hematura (some darkening)
• Post-void dribbling
• Fever (recently)
• Nausea/vomiting
• Diarrhea (none)
• Diaphoresis
• Current Medications
• Diet history (focusing on calcium and oxalate intake)
• Personal history of renal stones
• Personal history of urinary tract infections
• Family history of renal stones
• Past medical history

Physical Examination

Inspection/Vitals

• Comments on general appearance of patient (uncomfortable, diaphoretic)
• Measures heart rate (elevated) and states that temperature should also be measured

Renal Examination

• Palpates location of back in which pain is located
• Assesses for CVA percussion tenderness
• Attempts to palpates for kidneys with patient supine
• Auscultates for renal bruits bilaterally

Abdominal Examination

• Inspects abdomen for masses, scars
• Auscultates in all four quadrants of the abdomen
• Palpates all quadrants for tenderness, commenting on absence/presence of guarding
• Assesses for rebound tenderness in the left and right lower quadrants
• States that they would perform a digital rectal examination as part of the abdominal examination

Special Maneuvers

• Examines for signs of appendicitis: McBurney’s point tenderness, Rovsing’s sign, Psoas sign

You are seeing Bill Byrd, a 40 year old man in your outpatient clinic because he recently noticed a testicular mass. Perform a full genital examination.

Physical Examination

Scrotum

• Inspects scrotum for asymmetry and skin lesions
• Palpates testicles bilaterally
• Comments on masses: size, location, consistency, tenderness, irregular shape
• Palpates epididymis for tenderness, enlargement

Penis

• Inspects penis for erythema, swelling, deformity
• Palpates along penile shaft for irregularity
• Examines foreskin for signs of infection
• Exposes glans for inspection, and replaces the foreskin after completing the examination
• Examines meatus for discharge

Hernias

• Palpates inguinal region bilaterally for presence of hernias
• Assesses for hernias with patient standing up
• Asks patient to bear down during palpation of scrotum

Digital Rectal Examination

• States that a digital rectal examination would be performed as part of the genitourinary examination

You are seeing Mr. Ali, a 72 year old male, in your outpatient clinic today for ‘bloody urine.’ Take a focused history of his complaint.

History

• Onset and duration of hematuria
• Progression or worsening of hematuria
• Clarifies color of urine (bright red blood)
• Urinary frequency
• Pain on urination
• Urgency
• Nocturia
• Incomplete voiding
• Hesitancy
• Penile tip pain
• Flank Pain
• Abdominal discomfort/fullness
• Systemic Symptoms – weight loss, fever, night sweats
• Personal history of bleeding diathesis
• Personal history of renal stones
• Past history of renal disease
• Current medications
• Surgical history
• Smoking history (quantity in pack-years)
• Occupational history – especially exposure to exogenous toxins
• Concerns as to what is causing the hematuria
• Past history of urinary tract infections
• Family history of urogenital cancers

You are seeing Mrs. Singh, a 72 year old female, in your outpatient clinic today. She tells you that she has discomfort during urination and has difficulty controlling her urine. Take a focused history of his complaint.

History

• Clarifies symptom of dysuria
• Onset of dysuria
• Urinary frequency
• Change in urine color (cloudiness, darkening)
• Presence of hematuria (none)
• Nocturia
• Urgency
• Overflow Incontinence
• Incomplete voiding
• Flank/back pain
• Abdominal discomfort/fullness/pain
• Nausea and vomiting
• Fever
• Gastrointestinal symptoms such as pain, diarrhea, blood in stool
• Pregnancy history
• Current medications (particularly anti-cholinergic medication, estrogen creams)
• Past history of urinary tract infections
• Past history of urinary incontinence and treatments
• Exposure to pool/lake/ocean water
• Recent antibiotic use
• Effect on daily life