This is the case of 74 year old male patient heavy smoker (2 packs per day) presenting to the floor of MGH for the above chief complaints. History goes back to 15 days when the patient noticed 3 successive episodes of blood with urination at morning, one hour apart, painless ,of large amount, complete stream ,also the patient recorded that he saw 2 pieces of clots after voiding at noon of same day .then the color of urine was back to normal as the patient said. there’s associated nocturia, urgency, and drippling of one month duration .also weight loss of 15 kg within 3 months.NO burning sensation , no pain ,no dysuria, no fever ,no flank pain,no back pain, no nausea no vomiting, no constipation ,no other system involved symptoms. The patient was admitted to MGH for further investigations.
PMH : DM 25 years ago
HTN 10 years ago
CAD 10 years ago
Medications:
concor 5 mg one at morning
aspicot 100 mg OD
Lipitor 20 mg OD
glucophage 750 mg PO BID
amaryl 4 mg PO daily
tritase 10 mg PO daily
PSH: CABG, hemorroidectomy , left herniectomy, right hip fixation by plates and screws(duration unknown by the patient).
Family history: Mother(DM,HTN,CAD)
Allergy : No known drug or food allergy.
Physical examination:
General examination:
The patient is conscious, cooperative, oriented, pale, sitting, thin , cachectic ,having foley catheter.(seen 2 days postop) Vital Signs:
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RR: 24/min
Pulse: 64/min
Temp.: 37.4 C
BP: 160/90 mmhg.
HEENT : pallor, no cyanosis, no jaundice, no ecchymosis, no mouth ulcers , bad oral hygiene Decreased visual acuity (presbiopia) ,arcus senilis ,diplopia No tinnitus, no vertigo (Dix hallpike test not done)
Chest ex:good bilateral air entry. No rub, no crepitations, no wheezes. cardiac ex:
Regular S1S2 with no murmurs.
Abdomen ex:
1. Inspection:
– non distended symmetrical abdomen
No visible pulsation or peristalsis
No localized bulge
Male pattern of hair distribution
Umbilicus is slightly shifted downwards, no discharge
No full flanks
Normal subcostal angle
No spider angiomas
No visible veins
No scars, or scaling
red colored urine(in the foley’s bag) but the urine is clear due to irrigation of bladder 2.Auscultation: audible bowel sounds, no renal artery bruit
3.Palpation:
– soft non tender abdomen, warm, no palpable masses,
– Lower border of liver is not felt, upper border at 5th ICS along the MCL
– Spleen is not palpable
– Both kidneys are not palpable , no CVA tenderness.
– no suprapubic pain.
4.Percussion:tympanitic urinary bladder
5.DRE: not done
6.Genitalia examination: not done
Lower limbs :positive pedal pulses no lower limb edema, no redness no bruises no muscular atrophy.
Differential diagnosis:
1- bladder cancer
2- BPH
3- Prostatitis
4- Urolithiasis
5- Prostate cancer incidental or advanced.
Investigations :
Labs :
CBCD, BUN, Creatinine ,electrolytes, CRP, HBA1C,FBS,LDL,HDL,triglyceride PT ,PTT ,PSA, urine analysis and culture. Imaging :
CT urography(uroscan),cystoscope and urine cytology.
What was done at the hospital :
Item
Minumum
Maximum
Value pre op
Hemoglobin
Urine analysis : normal
Ultrasound of pelvis : no post residue voiding ,small thick wall, prostate is enlarged measuring 39 grams Management :
Control the glucose level preop
TURBT
TURP to relieve obstruction with biopsy of prostate
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Send the samples to pathology and wait the results.
If the tumor did not invade the detrusor muscle it’s superficial and managed according to grading and depth (Ta low grade TUPBT only ,T1 low grade or Ta high grade TURBT + intravesicle injection of chemotherapy , T1 high grade TUPBT and relook after 1 month) if invade the detrusor muscle : T2 = metastatic workup CT abdomen ,chest , and bone scan.then remove the bladder and do urinary divergence by neobladder or ileostomy(conduit).
