Case 44: Kim Hosking

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history. The facilitator will give you the results of the examination on request. Outline the most likely diagnosis to the patient and negotiate a management plan with him.

The following information is on his summary sheet:

• Past medical history

• Hypertension—diagnosed 2009

• Medication

• Perindopril 5 mg od

• Allergies

• Nil

• Immunisations

• Up-to-date, including influenza

• Social history

• Married

• Three children, now grown-up

• Ex-smoker.

INSTRUCTIONS FOR THE PATIENT, KIM HOSKING

You are a 70-year-old retired architect. Over the past few years your urine stream has become weaker. You pass urine more often and now have to get up about three times each night. You get frustrated that, having got out of bed, you then have to wait a while before the stream starts. It embarrasses you that you often dribble after passing urine, which wets your clothes.

Your blood pressure is currently well-controlled and except for the urinary symptoms, you enjoy being retired. Two weeks ago, at your blood pressure check, you mentioned to your GP that you had ‘waterworks trouble’. The GP suggested that you make an appointment to discuss this, which is why you are here.

The following information is on your summary sheet:

• Past medical history

• Hypertension—diagnosed 2009

• Medication

• Perindopril 5 mg od

• Allergies

• Nil

• Immunisations

• Up-to-date, including influenza

• Social history

• Married

• Three children, now grown-up

• Ex-smoker.

INFORMATION FOR THE FACILITATOR

Clinical examination findings

Temperature, pulse and blood pressure are within normal limits

Abdominal examination is normal

Rectal examination reveals a smooth, non-tender, symmetrically enlarged prostate.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to gain understanding of Kim’s ideas, concerns and expectations.

Specific questions

Details—urinary frequency, hesitancy, stream, nocturia, incomplete emptying, incontinence, terminal dribbling

Pain or dysuria

Haematuria

Fever

Systemic malaise, weight loss

Sexual function

Urethral discharge.

Ask for the examination findings

Temperature

Pulse

BP

Abdominal examination

• — Inspection

• — Palpation—exclude palpable bladder

Genitalia

Rectal examination to assess the prostate.

Most likely diagnosis

Obstructive lower urinary ...