Case 5 – Benign Prostatic Hyperplasia

Tan Li 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.)
Case 5 – Benign Prostatic Hyperplasia