BPH
Age: years old
Gender:
HISTORY:
Presents with a - history of obstructive urinary symptoms
Onset was
Symptoms include:
, , ,
, up to °, over
Worsening factors:
Alleviating factors: ,
Impact on is
No history of: , , , , , ,
No use of: , , , , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
ASSESSMENT:
DDx: benign prostatic hyperplasia, urethral stricture, bladder neck obstruction, prostate cancer, urethral calculus, bladder stones, urinary tract infection, neurogenic bladder, phimosis, paraphimosis, pelvic mass, constipation, medication side effect, pelvic floor dysfunction, foreign body in the urethra, meatal stenosis, posterior urethral valves, functional bladder outlet obstruction, pelvic organ prolapse, cystocele, spinal cord injury, neurologic disorder, genital HSV infection
PLAN:
Investigations:
- Urinalysis
- Urine culture
- Blood work: , ,
- Renal ultrasound
- CT scan of the abdomen and pelvis
- Uroflowmetry
- Post-void residual urine volume
Treatments:
- Avoidance of caffeine, alcohol, and large fluid intake
- Voiding diary
-
-
-
-
- Transurethral resection of the prostate
Further care:
- Referral to urologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as fever, hematuria, or urinary retention
HISTORY: EXAM: ASSESSMENT: PLAN: