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1. urinary hesitancy - difficulty iniatiating micturition in delay onset of voiding after individual is ready to urinate

2. urinary frequency - need to urinate more often

3. urinary urgency - sudden urge to urinate w\o full bladder

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1. 70-year-old male presented - immunocompromised, htn, diabetes, prostate ca, conscious, elderly: degenaration of cells, loss of bladder control

2. chief complaint of urinary frequency, urgency, and hesitancy. - uti, diabetes (neurological problems), bph

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further questioning

1. socrates

1. s - site

2. o - when symptoms occur

3. c - characteristics of pain (burning pain)

4. r - any other part feel any pain

5. a - hematuria, nausea, vomitting, weight loss

6. t - how often need to urinate, changes in urine volume

7. e - anything that makes it worse, take any medications or apply any heat (bladder contraction)

8. s - pain scale 1 -10

2. pmh - recurrent urinary infection, kidney stones, any comorbities such as htn, diabetes, parkinson, any surgeries, receive any testosterone therapy (could enlarge prostate, bph), predisposing factor of bph, fluid intake, volume of urine per day

3. drug history - medications and drugs

4. family history - any family members with prostate issues, uti, endocrine disorders (diabetes)

5. social history - occupation, dietary intake, fluid intake, alcohol & caffeine consumption, smoking, exercise habits, voiding habits, stress & emotional well being, sexual history

diff diagnosis

1. uti

2. diabetic nephropathy

3. prostitis

4. prostate ca

5. bph

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PSA blood test - prostate specific antigen. measure the amount of prostate antigen

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Further Ix:

1. Vital signs - Temp, HR, BP, RR

2. PE - check for abnormalities of size of bladder, palpate the abdomen, tenderness around kidney ( renal angle),

3. Digital Rectal Examination - abnormalities in the rectal and prostate gland, fast and painless

diff diagnosis

1. uti

2. diabetic nephropathy

3. prostatitis

4. prostate ca

5. bph

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waking up multiple times each night to urinate - nocturia, commo in older pt, when pt urinate a t least once or twice per night, causes, bladder infxn, alcohol, enlarge prostate gland, DM

symptoms began approximately 2 months ago - chronic

patient reports that he often has difficulty falling back asleep after awakening, and the loss of sleep was affecting his quality of life - dt nocturia, disrupt his leep pattern, insufficient sleep loss of energy for the next day, affect his daily activity

had a family history of prostate cancer and is concerned that prostate cancer is the source of his symptoms - risk to get prostate ca for first degree relative

The patient had a prostate exam including PSA blood test performed 15 years ago, with normal results - have no any signs of prostate ca at that time, still cant be urled out, prostae ca can develop gradually over time, increase with age, psa blood test not too accurate in detecting prostate ca, some med also can influence psa level, to ruled out this ca.. do DRE, biopsy

The patient was diagnosed with hypertension at age 55 and takes enalapril - not dierectly cause urinary sytem infxn, can influence prostate health, lead to htn related nephropathy, ada relation between HTN and prostate Ca (less evidence), enalapril ace inhibitors, ada side efects, persistent dry cough, can cause difficulty to sleep after nocturia, electrolyte imbalance, has renoprotective effects, having nocturia might cause HTN, insomnia, stress, when do psa with enalapril, false results

His father was diagnosed with prostate cancer at 62, died at age 86 and his brother was diagnosed with prostate cancer at age 43, still alive - has familial predisposition for prostate Ca, father: may suggest manageable (hidup lama), brother: concern, potentially more aggressive form of Ca, pt have high risk for prosta Ca

no known allergies revealed - allergies can impaired treatment decision

no history of smoking, alcohol consumption or drug abuse - the dx not iduced by these, maybe bcs of genetic, might no be complicated or worsen

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costovertebral angle - aka renal angle, angle between lower border of 12 th rib and lateral border of erector spine muscle

DRE - check for rectum, anus and prostate gland abnormalities

perineal sensation - ability to percieve touch, pressure, pain and temp in perineal area, mediated by nerve including pedundel nerve (S2-S4)

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all vital signs normal - bp normal means controlled hpt, temp normal absence of systemic infx, hr normal means no cvs event, rr normal so normal respiratory

no costovertebral angle tenderness - no kidney problem

bladder felt distended on palpation - bladder enlarged beyond normal size means bladder have lot of urine that not fully emptying, causes are bladder obstruction such as bladder stone, bladder tumor

genital exam normal - not enough to rule out prostate ca

DRE reveals prostate enlarged in size, smooth and non-tender with no nodules - more to BPH as no nodule (nodules more prominent for malignant), non-tender so painless (benign)

anal sphincter tone and perineal sensation is normal - no neurological dysfunction (more related to obstructive causes such as BPH)

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further investigation

blood test - FBC and RFT (check for creatinine, urea)

urinalysis - check for sign of infx or inflamm, check for appearence and content of urine (uti- cloudy appearance), to rule out uti

international prostate symptom score (IPSS) - answering questionare (such as urinary frequency or urgency) to check for severity of symptoms

prostate ultrasound - size, shape and location of prostate gland, ultrasound better than DRE

PSA test

prostate biopsy - know wether bph or prostate adenocarcinoma, no biopsy basically

cystoscopy - insert flexible tube with camera into bladder

uroflowmetry - help dr how well filter func of kidney, recommended in slow urination, abnormal suggest bph, urinary blockage and neurogenic dysfunction

diff diagnosis

1. uti

2. diabetic nephropathy

3. prostatitis

4. prostate ca

5. bph

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1. PVR urine volume - amount of urine left after urination.

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1. Blood test - Normal, Hb can rule out anemia, glucose rule out diabetes

2. Urinalysis - Normal, BPH does not cause uti, BPH does not associated with proteinuria.

3. IPSS score 21 and PSA 4.2 - Severe symptom, PSA also high, PSA also can elevate in normal condition sometimes does not indicate prostate CA.

4. Ultrasound enlarged prostate gland measuring 55 cc in volume and PVR 60 mL - Indicates benign hyperplasia.

5. Transrectal ultrasound-guided prostate biopsy showed benign prostatic tissue with stromal and glandular hyperplasia - No sign of prostate ca, glandular hyperplasia(enlargement of glandular tissue)

6. Diagnose with BPH - Condition in men which the prostate gland is enlarged.

7. Medication therapy tamsulosin and finasteride - Tamsulosin(alpha 1 blocker), finasteride(block testosterone production)

8. Follow up visit significant symptom improvement and life quality improvement and medication tolerated well. - after 1 week there is no side effects

9. Continue therapy with annual DRE and PSA -