You are an FY2 in a GP surgery  

Personal Details:

Name: Robert Green

Age: 62

Medical Record:

Past medical history: Hypertension.

Allergies: Penicillin.

Notes:

A 62-year-old man presents with a 7-day history of urinary symptoms (burning, foul-smelling urine)

Task:

1. Take a focused history and address his concerns.

2. Discuss the management plan.

The nurse completed a urine dip, which is as follows:

Leucocyte +ve, nitrate ++, protein +, erythrocyte trace 

Opening Sentence: “Doctor, I’ve got this awful burning when I pee, and it smells really bad. It’s been going on for a week.”

Open History (to give freely): “On top of that, for the last 12 months, I’ve been having other problems. I have to get up a couple of times a night to go to the toilet, I have to rush to get there in time, and then when I’m done, it keeps dribbling. It’s affecting my work; I have to sit near the toilet.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think I’ve got an infection, but I’m worried about the other symptoms.”

Concerns: “Is it cancer? My friend had prostate cancer.”

Expectation: “I want some antibiotics for the infection, and I want to know what’s causing the other problems.”

How to Act: You are anxious and uncomfortable due to your symptoms. Your main worry is cancer.

More History (only if asked): You feel a bit feverish, but haven’t checked your temperature. You have no visible blood in your urine. Your bowel habits are normal. You have no family history of prostate cancer. You are eating and drinking as normal and feel generally well in yourself. You haven’t had any weight or appetite change, no lumps or swelling, and no unusual back pain.

Social History: Works as an accountant.

Questions to ask:

“So you don’t think it’s cancer?”

History of Presenting Complaint:

Tell me what symptoms you’ve been having. You mentioned stinging. How long has that been going on?” “How often do you need to go to the toilet during the day? And at night? Do you feel like you’re emptying your bladder?

Red Flag Screening (for pyelonephritis/sepsis): Have you had any fever or felt hot and shivery? Have you had any pain in your lower back or sides? Have you seen any blood in your urine?

Review of Underlying Condition (BPH): before the last week, how were your usual waterworks? Were you having any problems with a slow stream or dribbling?

ICE (Ideas, Concerns, Expectations): You thought it was an infection. What were your concerns about it? What were you hoping I would do for you today?

Explain the situation, the likely diagnosis or DD:

Robert, thanks for coming in. It sounds like you have two things going on. The recent burning and smelly urine are very typical of a urinary tract infection (UTI), and we need to treat that. The longer-term symptoms you’ve described – the getting up at night, the urgency, and the dribbling – are what we call lower urinary tract symptoms, or LUTS.”

Addressing and answering the patient’s ICE:

You’re worried this could be cancer, which is a very understandable concern. While we can never be 100% certain without tests, these symptoms are most commonly caused by a non-cancerous condition called Benign Prostatic Hyperplasia, or BPH. This is a very common, age-related enlargement of the prostate gland. As the prostate gets bigger, it squeezes the tube from the bladder, causing all the symptoms you’ve described. It can also stop you from emptying your bladder properly, which is likely why you have developed a UTI.”

Next Steps:

Today, we need to treat the infection. I will prescribe you a course of antibiotics. As you are allergic to penicillin, I will choose a different type. We also need to send a sample of your urine to the lab to confirm the infection and check which antibiotic works best.

After 2-4 weeks (As PSA is falsely raised during UTI), I will arrange for you to have some blood tests, which will include checking your kidney function and a test called a PSA, which is a blood test for the prostate. I will also need to perform a gentle rectal examination to feel the prostate gland. This is an important part of the assessment.

Once the infection is cleared, we can start you on a medication that helps to relax the prostate gland and improve the flow of urine.

So, the plan is: antibiotics for the infection, urine and blood tests after 2- 4 weeks with a physical examination, and then starting a new medication for the prostate symptoms once the infection has settled.

Addressing ideas, concerns, and expectations: Reassure him that BPH is a much more likely diagnosis than cancer, but acknowledge that cancer needs to be ruled out. Explain what BPH is in simple terms.

The management plan has two parts. Acutely: 1. Prescribe a non-penicillin antibiotic for the UTI (trimethoprim 200mg BD for 7 days) 2. Send a urine sample. Chronically: 3. Arrange blood tests (U&Es, PSA) after two weeks of treating the infection. 4. Arrange a follow-up and explain the need for a digital rectal examination (DRE).

What is scenario testing? This case tests the candidate’s ability to manage a patient with two related but distinct conditions (UTI secondary to BPH). It requires knowledge of the investigation and management of both. The communication challenge is to reassure the patient about his cancer fears while still outlining a thorough investigation plan to rule it out.