Presentation on theme: "MODULE 5 1/24 Case 7: John. MODULE 5 Case 7: John 2/24 Patient History John is a 64-year old retired school teacher. You recently sent him to see."— Presentation transcript:
MODULE 5 Case 7: John 2/24 Patient History John is a 64-year old retired school teacher. You recently sent him to see his urologist for an assessment. He is quite worried because his recent PSA is 2.5 ng/mL, which is up from the last recorded value 1 year ago at 1.2 ng/mL. John is now concerned that his mild lower urinary tract symptoms (LUTS) indicate that he has newly developed prostate cancer. His friend was recently diagnosed with prostate cancer. PSA = Prostate-Specific Antigen
MODULE 5 Case 7: John 3/24 What Typical Questions Do You Have for John?
MODULE 5 Case 7: John 4/24 1.Has your urine stream changed? 2.Do you have to get up at night to urinate? 3.Does it burn when you urinate? 4.Have you had a fever? 5.Has there been any blood in your urine? 6.Questions around irritative and obstructive symptoms 7.Questions examining possibility of diabetes 8.How much do your symptoms bother you? 9.Is there any history of prostate cancer in your family? Some Possible Questions for John
MODULE 5 Case 7: John 5/24 John’s Response John says his urine stream has changed He now rises to void five times nightly and has moderate urgency during his working day. His stream is slow but he has never had any episodes of urinary retention.
MODULE 5 Case 7: John 6/24 In Your Practice, How Would You Determine the Severity of John’s Symptoms at this Stage?
MODULE 5 Case 7: John 7/24 Use of Questionnaires: 1.IPSS (or AUA symptom score) 2.Quality of life question IPSS = International Prostate Symptom Score AUA = American Urological Association
MODULE 5 Case 7: John 8/24 Discussion The IPSS and Quality of Life due to Urinary Symptoms Questionnaires are requested of John You ask him to complete the forms before proceeding Here are John’s scores: International Prostate Symptom Score (IPSS) Patient name: John DOB: 05/05/41 ID: 0019-0027 Date of assessment: 29/06/05 Initial assessment (X) Monitor: during __X__ therapyafter _____therapy/surgery
MODULE 5 Case 7: John 9/24 International Prostate Symptom Score Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always John’s Results 1. Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 0123453 2. Over the past month, how often have you had to urinate again less than two hours after you finished urinating? 0123453 3. Over the past month, how often have you found you stopped and started again several times when you urinated? 0123451 4. Over the past month, how often have you found it difficult to postpone urinating? 0123454
MODULE 5 Case 7: John 10/24 Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always John’s Results 5. Over the past month, how often have you had a weak urinary stream? 0123453 6. Over the past month, how often have you had to push or strain to begin urinating? 0123454 None1 time2 times3 times4 times 5 or more times John’s Results 7. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0123454 Total IPSS Score = 22
MODULE 5 Case 7: John 11/24 John’s Bother Score = 3 (mixed bother) Quality of Life Due to Urinary Symptoms DelightedPleased Mostly Satisfied Mixed about equally satisfied and dissatisfied Mostly dissatisfi ed UnhappyTerrible 1. If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 0123456
MODULE 5 Case 7: John 12/24 How Do You Interpret the Severity and Bother of John’s Symptoms?
MODULE 5 Case 7: John 13/24 Interpreting the IPSS and Bother Score IPSS Values Indicate Symptom Severity: Mild score: ≤ 7 Moderate score: 8-19 Severe score: ≥ 20 John’s IPSS = 22 (severe symptoms) John’s Bother Score = 3 (mixed bother) IPSS = International Prostate Symptom Score
MODULE 5 Case 7: John 14/24 What Physical Examinations Do You Undertake on John?
MODULE 5 Case 7: John 15/24 Recommended Examinations: 1.Abdominal exam 2.Genital exam 3.DRE 4.Blood pressure DRE = Digital Rectal Examination
MODULE 5 Case 7: John 16/24 Physical Examination HR68 bpm Blood Pressure115/75 mmHg Urinalysis Clear Midstream specimen for culture show no growth Abdominal ExamNormal Genital ExamNormal DRE DRE reveals moderate sized smooth non-tender gland DRE = Digital Rectal Examination
MODULE 5 Case 7: John 17/24 What Investigations Might You Consider for John at this Stage of the Consult?
MODULE 5 Case 7: John 18/24 Urethral swab: negative Blood/Glucose: negative PSA: 2.5 ng/mL Urinalysis: no abnormal findingsLab tests: Lab Results PSA = Prostate-Specific Antigen
MODULE 5 Case 7: John 19/24 Management Strategy John’s mixed bother and high IPSS are indications of a need for further evaluation Furthermore, his elevated PSA level of 2.5 ng/mL, while not extremely high, warrants referral to a urologist. IPSS = International Prostate Symptom Score PSA = Prostate-Specific Antigen
MODULE 5 Case 7: John 20/24 Urologist Feedback John’s prostate size measurement via DRE is critical for monitoring his condition Measurements (4.2 x 5.2 X 5.5 cm) give a calculated volume of 63 ml and technician observed that the bladder was not completely empty after voiding. DRE = Digital Rectal Examination
MODULE 5 Case 7: John 21/24 Long Term Follow-up John is placed on combination therapy of a 5α-reductase inhibitor and an α 1 -blocker The PSA is expected to decrease by approximately 50% in the first 6- 12 months and then not rise appreciably while on 5α-reductase inhibitor. He is monitored annually via DRE and PSA DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen
MODULE 5 Case 7: John 22/24 Is there anything else the GP should do or discuss with this patient, besides annual monitoring of DRE and PSA? Long Term Follow-up DRE = Digital Rectal Examination PSA = Prostate-Specific Antigen
MODULE 5 Case 7: John 23/24 This 64 year old gentleman with a PSA of 2.5, benign enlarged prostate gland should be reassured that his risk of clinically important prostate cancer is small. He needs to have continued monitoring. He is quite symptomatic and treatment with combination therapy has been initiated. If his PSA starts to rise while on 5α-reductase inhibitor treatment then referral back to urologist is indicated. He could be told that 5α-reductase inhibitor therapy with finasteride has been shown in a study to reduce the risk of future development of prostate cancer. Long Term Follow-up PSA = Prostate-Specific Antigen