1. Benign Prostatic Hyperplasia

2. BPH  Benign increase in size of prostate  Hyperplasia of stromal and epithelial cells  Nodules

3. Patient W.M.  76 yo  Recurrent UTIs  Acute pyelonephritis  Urinary frequency, urgency, incontinence, and nocturia

4. Past Medical History  Hypothyroidism  COPD  Obesity  1 ppd smoker  Father – alcoholic  Mother – DM type 2

5. Review of Symptoms  Strain to initiate urination  Urinary flow stops and then starts  Post-void dribbling

6. Medications  Ipratropium bromide  Ibuprofen  Levothyroxine  Ferrous sulfate

7. Case Question 1: For what condition is the patient probably taking ipratroprium bromide?

8.  Ipratropium bromide is used to relieve bronchial spasms  Anticholinergic

9. Answer : COPD

10. Case Question 2: For what condition is the patient probably taking levothyroxine?

11.  Synthetic thyroid hormone

12. Answer: Hypothyroidsim

13. IPSS  International Prostate Symptom Score  8 question survey  Standardize patients

14. Case Question 3: Based on the patient’s IPSS, is his condition of prostatic enlargement considered mild, moderate or severe?

16. Case Question 4: Based on the patient’s BMI, is the patient technically overweight or obese?

17. BMI  Measure of body fat  Underweight < 18.5  Normal weight = 18.5-24.9  Overweight = 25-29.9  Obesity > 30

18. Vital Signs  Patient’s BMI = 33.8% BP 135/85 (R arm) 130/85 (L arm) RR 16, unlaboredHT 6’0” P 80 and regularT 98.6 FWT 249 lbs

19. Physical Exam  All normal  Urinary Function Tests  Uroflowmetry  Transabdominal ultrasound  Pressure flow study

20. Case Question 5: Which urinary function test(s) is/are consistent with an enlarged prostate?

21.  Uroflowmetry  Normal: 10 – 21 mL/sec  Patient: 7 mL/sec  Residual Urine Volume  > 50 mL significant  Patient: 110 mL  Bladder Voiding Pressure  Weak < 100 cm H 2 O  Patient: 74 cm H 2 O

22. Case Question 6: Identify all abnormal results of this patient’s urinalysis

23. Color StrawBilirubin (-)WBC 2/HPF Appearance ClearKetones (-)RBC 2/HPF SG 1.017Blood (-)Bacteria Trace pH 6.4Urobilinogen (-)Crystals (-) Glucose (-)Nitrites (-)Culture Not indicated

24. Blood Test Results Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

25. Case Question 7: Is the patient experiencing an electrolyte imbalance?

26. Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

27. 8. Renal Function? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

28. 9. Hepatic Function? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

29. 10. Hb, Hct, MCV, MCH, MCHC? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

30. 11. T 4 and TSH? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

31. 12. Single most significant result? Na 141 meq/L MCHC 31.8 g/dLLDH 219 IU/L K 3.9 meq/L Plt 282000/mm 3 Bilirubin 1.2mg/dL Cl 109 meq/LWBC 8700/mm 3 Protein 5.9mg/dL HCO 3 32 meq/L Neutros 65% Cholesterol 255mg/dL BUN 15 mg/dL Lymphs 27%Ca 8.7mg/dL Cr.8 mg/dL Monos 5%Mg 2.2mg/dL Glu 119 mg/dL Eos 2%PO 4 2.8mg/dL Hb 13.9 g/dL Basos 1%Uric acid 6.3mg/dL Hct 41%AST 31 IU/LT 4 3.5µg/dL MCV 97 fLALT 41 IU/LTSH 107.9µU/mL MCH 28.7 pg Alk phos 52 IU/LPSA* 5.2ng/mL *PSA 13 months ago was 5.0 ng/mL

32. Case Question 13: Provide three strong lines of evidence that this patient does not have prostate cancer

33. 1. Low PSA 1. Physical exam findings 1. Low WBC count

34. Case Question 14: Pharmacotherapy or surgery?

35. Case Question 15 : When a patient with mild-to-moderate BPH does not respond to pharmacotherapy with 5α-reductase inhibitors or α1-blockers, what can be inferred?

36. the end