Difficulty in Urination
Trigger 1
Patient with complaint of “Difficulty in Urination!”
Questions:
1. What is “difficulty in urination”?
2. What are the more common types of “difficulty of urination”?
3. What are the more common causes of “difficulty in urination”?
4. What are the more common types of people who may present with a complaint of “difficulty in urination”?
Persons with real risk factors
past history It has the greatest risk for recurrence.
family history What are the renal problems with a great genetic predisposition?
environmental risks What are the environment- occupation-
(including occupational) associated renal problems?
psychosocial risks What are the commonly known lifestyle-
(including lifestyle) associated renal problems?
Persons with imagined risk factors
What types of people are these?
Others that you can think of?
5. What will be the management approach to a patient presenting with a chief complaint of “ difficulty in urination”?
Goals in the management of a patient
Screening for a health problem (renal problem)
Solution of a health problem (renal problem, if present)
Functions of a physician
Steps in the management of a patient
6. What is the gold standard in the diagnosis of an actual renal problem in patients complaining of “difficulty in urinaiton”?
7. What are the principles of treatment of patients complaining of “difficulty in urination”?
Difficulty in urination
Trigger 2
Scenario 1:
40-year-old female with chief complaint of “I have difficulty in urination”.
History:
Since 3 days ago, patient claims to have difficulty in urination.
She describes the difficulty in urination as “discomfort” during urination.
There are no associated symptoms like change in the color and character of
the urine and fever.
Physical examination:
No unusual findings and no gross abnormality noted.
Scenario 2:
50-year-old female with chief complaint of “I have difficulty in urination”.
History:
Since 3 years ago, the patient has been experiencing on-and-off
“difficulty of urination.” She describes the problem as hesitancy or
difficulty in starting urination, and once started, the stream of urine is small
and there is lack of force.
There is no change in color and character of the urine and no
associated symptoms.
Physical Examination:
No unusual findings.
Scenario 3:
50-year-old male with chief complaint of “I have difficulty in urination”.
History:
Since 2 months ago, he feels he is not evacuating all that he feels he
should evacuate during urination. As a result of this, he often goes to the
restroom to urinate. He goes to the restroom about 8 times during daytime
and once in the evening.
There are no associated symptoms.
Physical Examination:
No unusual findings.
Questions:
1. What is your primary and secondary diagnosis?
Primary diagnosis: _____________________________________________
Secondary diagnosis: ___________________________________________
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
4. Do you need a paraclinical diagnostic procedure?
If yes, why? If no, why?
Demonstrate use of
1. certainty/uncertainty of primary and secondary diagnoses
2. plan of management for primary and secondary diagnoses
3. others
5. If you need a paraclinical diagnostic procedure, what will you recommend? Why?
Give at least 3 options and then compare using benefit, risk, cost, and
availability factors. Then select one demonstrating priority on the primary
diagnosis. Shotgun policy is NOT acceptable.
Benefit Risk Cost Availability
Option 1
Option 2
Option 3
6. Suppose the patient agreed to your recommendation of the paraclinical diagnostic
procedure and suppose it was done.
What results will firm up your primary diagnosis?
What results will make you shift to your secondary diagnosis as the primary
diagnosis?
Difficulty in urination
Trigger 3.
A paraclinical diagnostic procedure was done.
[Either utilize the one recommended by the student or the facilitator presents a prepared one.]
A urinalysis was done (within normal limts).
[Here is the picture/reading/result of the paraclinical diagnostic procedure. ]
Questions (as applicable):
1. Examine the result of the paraclinical diagnostic procedure and then interpret.
Decide whether the result is informative or non-informative.
Informative, why? Non-informative, why?
2. After the paraclinical diagnostic procedure, what is now your primary and secondary
diagnosis? Why?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Diagnostic Procedure/Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need to firm up your diagnosis before you proceed to treatment?
If yes, how?
What data do you need?
History?
Physical exam?
Other diagnostic procedure?
Observation and monitoring?
[Data asked for either not available or normal. Facilitator may supply other data.]
4. What is your pretreatment primary and secondary diagnoses?
5. State the goals of treatment for your primary diagnosis?
6. Decide on a treatment modality after comparing the options based on benefit, risk,
cost, and availability factors.
Benefit Risk Cost Availability
Nonoperative
(Specific procedure in mind)
Operative
(Specific procedure in mind)
8. Describe the things need to be done during the pretreatment, intratreatment, and posttreatment phase.
7. Decide how you would evaluate the results or outcome of your proposed treatment.
Difficulty in urination
Trigger 4
The diagnosis of the patient’s health problem is
No organic pathology to explain the difficulty in urination
Questions :
1. Advice the patient and relatives on the pathophysiology of the disease or condition
(the diagnosis is: no organic pathology to explain the “difficulty in
urination”)
Use diagram.
2. Advice the patient and relatives on screening of the disease (i.e., renal problem)
3. Advice the patient and relatives on early detection of the disease (i.e., renal problem).
Difficulty in urination
Trigger 5
A case write-up of a patient with a complaint of “Difficulty in urination”
DIAGNOSIS IS NOT SPELLED OUT!
Signs and symptoms
Course in the management
Paraclinical diagnostic procedures done
Treatment
Outcome
Questions:
1. Study the case and then decide on the primary and secondary diagnoses.
Give bases for your diagnoses using
pattern recognition with pathophysiology
prevalence
2. Study the case and then
2.1 Comment on the outcome of treatment.
Were the goals of treatment achieved? Yes, why? No, why?
2.2 Describe the prognosis after treatment.
Recurrence, survival, quality of life
Pathophysiology of the disease leading to physical disability and death
Difficulty in Urination
A Case Study
A 50-year-old male consults because of difficulty in urination which he describes as difficulty in starting urination and once started, the flow is not continuous and he always feel there is inadequate evacuation of his urinary bladder.
There are no associated symptoms.
Rectal examination shows a mass on the prostate.
A prostatic biopsy was subsequently done.
He was subsequently subjected to an operation and then orchiectomy and then radiation because of bone pains.
He died 3 years after diagnosis.
ROJ@17nov6