6512 Week 10 iHuman I am Peeing All the Time
Reason for encounter
I am peeing all the time
History of present illness (HPI)
A 62 year old reports urinating more frequently for the past six weeks, urinary hesitancy, urgency, and nocturia. During the day, he urinates every two to four hours and at night, he wakes up atleast twice to urinate. He takes up to 30 minutes to fall back asleep hence, he barely gets enough sleep. With every bathroom visit, the amount he urinates is lesser. Although he denies straining with urination, he has to be patient and wait for urine to start flowing which can last between few seconds to thirty seconds. Every 1 in 5 occasions that he urinates, he has noticed some terminal dribbling where the urine stream starts and stops but other times, it starts and starts. In the past month, he has had a sense of incomplete bladder emptying about half the time. He denies pain with urination, abdominal pain, flank pain, pan with intercourse, chest pain, blood in urine, foul odor in urine, weight gain/weight loss, fevers, night sweats, or chills.
Diagnostic Tests
- Urinalysis (UA)
- Urine culture
- Basic metabolic panel
- Prostate specific-antigen(PSA), blood
Problem Statement
The patient is a 62-year old male with PMH of hypertension, hyperlipidemia, and a FH of prostate cancer who presents with a 6-week history of urinary frequency, urgency, hesitancy, and nocturia at least twice per night. He denies fever, chills, nausea, vomiting, and hematuria. Erectile dysfunction, or abdominal, perineal or bone pain. Physical examination reveals stable vitals and a symmetrically enlarged, smooth prostate gland without tenderness or focal lesions. The remainder of the physical examination is unremarkable.
Plan Feedback
Pharmacologic Care
- Begin tamsulosin 0.4mg PO daily at bedtime. Will consider increasing to 0.8 mg based on symptoms
- If tolerating tamsulosin after 14 days, may begin dutasteride 0.5mg daily
- Continue amlodipine and rosuvastatin as previously prescribed
Supportive Care
- Lifestyle modification discussed
- Limit fluids to sips of water 1-2 hours prior to bedtime
- Reviewed bladder irritants(alcohol, caffeine, spicy foods, etc)
- Sitting to urinate vs. standing may facilitate bladder emptying and reduce symptoms (reasonable to try prior to bed)
- Limit salt intake
- Limit fatty food and sugars, try to eat leafy greens and lean proteins
Patient education
- Educated patient and family on diagnosis as well as risks and benefits of medical management
- Discussed potential side effects of medication, including orthostatic hypotension and potential dizziness with tamsulosin which is why QHS administration is recommended. If any side effects occur, the patient should stop the medication and contact the office
- Explained the different MOA of tamsulosin and dutasteride as well as the fact dutasteride often takes several months to achieve benefits
- Both medications are intended to be long term daily medications and should be taken consistently and at the same time each day
- Discussed PSA results, further decision by urology
- Encouraged increased activity levels to include up to 150 minutes of moderate activity per week
Follow-up
- Interval follow up on medical therapy in 3-4 months to assess change in symptoms, sooner if problems or concerns.
- Will re-administer IPSS at that time and compare to today’s result
- Recheck PVR at that time as well
- Refer to urology for additional workup and treatment, including discussion of surgical options
- Will need routine prostate screening (DRE, PSA) based on family history
- Return in 2 weeks for primary care check up with lab work complete (note: if not previously ordered, checking on CBC, CMP, and lipids is relevant).
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