You are an FY2 in GP surgery

Personal Details:

Name: Mr Frank Miller

Age: 55

Medical Record:

Past medical history: None.

Notes:

A 55-year-old man is attending the well-man clinic for follow-up.

He has been experiencing urinary frequency during the day and nocturia (waking twice a night) for the past 6 months.

Your colleague saw him and underwent blood tests, including a PSA, FBC, LFTs, U+E, and HbA1c test, all of which were normal (blood was done four weeks ago)

He is coming back with some concerns.

Task:

1. Take a focused history of his urinary symptoms and perform a relevant examination.

2. Address his concerns and discuss the management plan.

Opening Sentence: “Doctor, I’m here to follow up on my tests. I was told by the receptionist that my PSA was normal, but I’m still worried.

Open History (to give freely): “I’ve been getting up a couple of times a night to pee for about six months now, and I seem to be going more often in the day too. I don’t have any pain or burning, and the stream is okay, I think. It’s just the frequency that’s annoying.

Cues to give: “The first test was a few weeks ago. Can’t it change in that time?”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think I might have early prostate cancer that the first test missed.”

Concerns: “I’m really worried about getting cancer like my friend. He had no idea.”

Expectation: “I expect you to repeat the PSA test today to put my mind at rest.”

How to Act: You are anxious and fixated on the idea of cancer. You are not easily reassured by the previous normal result.

More History (only if asked): You have no trouble starting urination, no dribbling at the end, and no feeling of incomplete emptying. You are otherwise fit and well.

You haven’t had any UTI symptoms like pain, stinging, blood in urine or a change in urine colour.

You haven’t had any red flag symptoms like weight or appetite loss, no fever, no lumps or swelling.

Social History: Office worker.

Questions to ask:

“So what is causing my symptoms if it’s not cancer?”

“Why won’t you just repeat the test? It’s just a blood test.”

Examination findings:

Abdomen exam: soft, non-tender, no lumps or swelling

PR exam: Moderately enlarged prostate. Smooth surface, well-felt border and sulci, no hardening or nodularity 

Opening & Exploring Anxiety:

Mr Miller, I can see that we have seen you before for the same symptoms, but you are worried today. Let’s go through the urinary symptoms in a bit more detail. How many times do you get up at night to pass urine? (Nocturia)

And during the day, how often are you going? (Frequency)

When you need to go, do you have to rush to the toilet? (Urgency)

How is your stream? Is it strong? (Weak stream)

Do you have any trouble getting started? (Hesitancy)

Do you find you are dribbling at the end? (Terminal dribbling)

Do you feel like you’ve completely emptied your bladder afterwards? (Incomplete emptying)

Red Flag Screening:

Have you ever seen any blood in your urine?

Have you had any pain when you pass urine?

Have you had any new back pain?

ICE (Ideas, Concerns, Expectations):

You think the first test might have missed something. What makes you think that?

You are worried because your friend had cancer. Is there anything else you are worried about?

Explain the situation, the likely diagnosis or DD:

Mr Miller, it’s completely understandable that you’re worried, especially after what happened with your friend. Let’s talk through your symptoms and concerns properly.

(After examination, which would include an abdominal exam and offering a digital rectal examination (DRE) of the prostate)

I’ve examined you, and everything feels normal apart from the enlarged prostate, which is a common finding in your age. Your symptoms of urinary frequency, both day and night, are what we call Lower Urinary Tract Symptoms, or LUTS. In a man of your age, the most common cause by far is a non-cancerous enlargement of the prostate gland. This is called Benign Prostatic Hyperplasia, or BPH. It’s a normal change most men get at some point above the age of 50.

Addressing and answering the patient’s ICE:

Your main worry is cancer. The good news is that your PSA blood test was normal, and you don’t have symptoms to suggest cancer, which makes cancer much less likely. You asked about repeating the test. The PSA test is not a perfect test for cancer. It can be raised for many reasons, including BPH, and repeating it so soon is not necessary and is unlikely to give us any new information. A normal result is very reassuring.

Next Steps:

Instead of focusing on repeating the test, we should focus on managing your symptoms. The first step is to look at some simple lifestyle changes. For example, reducing your intake of caffeine and alcohol, especially in the evening, can often significantly reduce the frequency of urination and the number of times you have to get up at night.

We can also try something called bladder training, which involves gradually increasing the time between visits to the toilet to help your bladder hold more. I can give you a leaflet about this. If these simple measures don’t help over the next few months.

We can also consider starting a medication, such as Tamsulosin, which helps to relax the muscles of the prostate and improve the flow. (400mcg OD)

I know you are still worried about cancer. What we can do is agree on a plan for sensible monitoring. We don’t need to repeat the PSA now, but we can agree to re-check it in a year’s time, or sooner if you develop any new, worrying symptoms like pain, blood in the urine, or unexplained weight loss. For now, all the evidence points towards a benign, manageable condition. Let’s focus on getting your symptoms better.

The management is a stepwise approach to LUTS. 1. Provide reassurance. 2. Advise on lifestyle changes (fluid/caffeine intake). 3. Explain bladder training. 4. Discuss medication (e.g., an alpha-blocker) as a next step. 5. Create a sensible safety-netting and follow-up plan (e.g., re-check PSA in one year) to allay his anxiety.

What is the scenario testing: This case tests the candidate’s ability to manage a common presentation (LUTS) complicated by significant health anxiety. It requires knowledge of the initial management of BPH and the principles of PSA testing. The communication challenge is to refuse a patient’s request for a test while maintaining their trust and providing reassurance, by offering a clear alternative management and follow-up plan.