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NR601 Week 5:Case Presentation
Summary
Patient Information Mr. K., 70 y/o, Male, Native American. CC : Nocturia and urinary frequency. HPI: Mr. K. is a 70-year-old Native American male who presents with complaints of nocturia. He indicates that he has been waking up to urinate more than 3 times each night. In addition, he reports having urinary frequency during the day, starting and stopping a stream, and doesn't feel like his bladder is completely empty after urination. He denies any pain on urination, fever or chills. His last PSA 2 years ago was negative. S. Onset: Not reported Location: Genitourinary Duration: Constant. He has this urinary symptoms day and night time. Characteristics: He has been up more than 3 times each night Aggravating Factors: reports he has urinary frequency in the daytime, starting and stopping a stream, feels he is not emptying the bladder after each use. Relieving Factors: None reported Treatment: None reported Current medications: Ibuprofen OTC as needed for joint pain.
ALLERGIES: NKDA
PMH: Arthritis in both knees. Social history: non-smoker; drinks 2-3 beers on the weekend Diagnostics Test: Last PSA was 2 years ago. ROS GENERAL CONSTITUTION: No fever, chills or fatigue. HEENT: Unremarkable SKIN: Dry and intact CARDIOVASCULAR: No CP/SOB, palpitations or edema RESPIRATORY: Denies sob, wheezing, cough or bloody sputum GASTROINTESTINAL: No complaints reported GENITOURINARY: Reports of nocturia that has been waking him up to urinate more than 3 times each night. He is also having urinary frequency during the day, starting and stopping stream, felling like his bladder is not emptying completely after urination. NEUROLOGICAL: No complaints reported MUSCULOSKELETAL: Patient has hx of arthritis in both knees HEMATOLOGIC: LYMPHATICS: No lymphadenopathy reported PSYCHIATRIC: Denies feeling depressed or anxiety ENDOCRINE: Denies signs and symptoms of hypo or hyperglycemia ALLERGIES: No history of asthma, hives, eczema or rhinitis. O General: no distress; no weakness or fatigue
longer than 30 minutes (National Clinical Guideline Centre, 2014). Mr. K. is a 70- year-old Native American male with arthritis in both knees. Differential diagnosis. Overactive Bladder (OAB) (N32.81): characterized by urinary symptoms including urgency, frequency, and nocturia, with or without urge incontinence (American Urological Association, 2012; Gormley et al., 2015). Urinary frequency is defined as voiding 8 or more times in a 24-hour period. Nocturia is defined as the need to wake 1 or more times per night to void. There are two main
underlying mechanisms of OAB: mechanisms with increased sensory (afferent) activity and mechanisms with abnormal management of afferent signals (Palmer, & Choi, 2017). The prevalence and severity of symptoms increase with age, and most patients have symptoms for years. Aging, an enlarged prostate, and diabetes are all risk factors. Mr. K c/o of nocturia, urinary frequency (urinate more than 3 times each night) make a diagnosis of OAB a real possibility. Urinary tract infection (UTI) (N39.0): infection of the lower urinary tract usually resulting from gram negative enteric bacteria (Michels, & Sands, 2015). UTI happens when urethral organisms enter bladder during micturition, multiply- pass up the ureter to the renal pelvis and parenchyma (Flores-Mireles, Walker, Caparon, & Hultgren, 2015). The population most likely to experience UTIs is the elderly due to a weakened immune system. UTI is characterized by urgency, frequency, burning, dysuria and offensive urine, itching, hematuria, suprapubic tenderness, sensation of bladder fullness, and lower abdominal pain; fever may or may not be present bacteria (Michels, & Sands, 2015). An acute onset of hesitancy, nocturia, slow stream, and dribbling have a predictive value for UTI of about 33% (Goroll, & Mulley, 2014). Mr. K presented with nocturia, urinary frequency (urinate more than 3 times each night) and voiding symptoms such as feeling of incomplete emptying, and hesitancy (starting and stopping a stream) which frequently indicate the presence of UTI.
c/o of nocturia, feelings of not emptying bladder completely and he is an older man. He presents to the clinic with complaints of nocturia. He reports that he has been waking up more than 3 times each night to urinate. He added having urinary frequency during the day, starting and stopping a stream, and doesn't feel like his bladder is completely empty after urination. He denies any pain on urination, fever or chills. Last PSA 2 years ago was negative. Routine labs/diagnostics : A urine culture: to rule out infectious causes related to voiding problems. Serum prostate-specific antigen level in correlation with prostate volume which will help guide the treatment choice. Urinalysis: In all patients with LUTS to assess for the presence of blood, leukocytes, bacteria, protein, or glucose. It can help rule out other etiologies such as bladder stones, cancer, UTI, or urethral strictures. Blood chemistry for electrolytes imbalances, BUN, and Creatinine to assess for renal insufficiency. Also CRP for inflammation response d/t arthritis, as well as 25- hydroxyl vitamin D level, Blood glucose, A1C level Bone Density/ Dextra test for screening of osteoporosis and osteopenia Additional Diagnostic Tests: No further testing is needed in uncomplicated LUTS. Additional testing is recommended when symptoms do not respond to
medical treatment, or when underlying disease is present. It is required to have the following testing: uroflow which is the volume voided per unit flow i.e. peak flow < 10mL is abnormal- postvoid residual done either with catheterization or bladder ultrasound > 100 ml which is incomplete bladder emptying (Pearson & William, 2014). These tests can be done as routine evaluation. But other testing can be considerate in advance disease process such as transrectal ultrasound for gland size assessment, and abdominal ultrasound for increased post voiding residual or hydronephrosis. Other diagnostic studies are necessary to determine etiologies of unresolved symptoms despite treatment management such as pressure-flow studies- urine flow vs, voiding flow- for instance in obstruction patterns. Another test is cystoscopy which will show the presence, the configuration, the cause-stones or strictures- and site of obstructive structures. Cystoscopy can be a valuable testing in the presence of hematuria and can help in treatment option (Goroll, 2014). Seven-item American Urological Symptom index may help determine the severity of symptoms (Goroll, 2014; Barry et al., 2017). Plan Pharmacological Treatment Medication for BPH : Alpha-Adrenergic antagonist and 5 alpha- reductase inhibitors are first line options for moderate to severe BPH (AUA, 2012).
ā¢ Ibuprofen 400 mg orally three times daily for 4 weeks (long term use of
NSAID is associated with renal insufficiency, GI bleeding , and blood pressure elevation) (ACR, 2012; NCGC, 2014).
ā¢ Voltaren gel 1% apply 4 g on affected joint prn from 2 to 4 times a
day (Cohen & Lee, 2015).
ā¢ Prilosec 20mg once daily as a prevention for GI problems
(Ferri, 2016).
ā¢ Caltrate 600+D, Take 2 tablets daily with meals as a supplement to help
rebuilt joints. Patient is at risk for osteoporosis. Calcium is essential for the body and can help with osteoporosis (Christakos et al., 2016; Ferri, 2016).
ā¢ Dietary supplements: Glucosamine and chondroitin (ACR, 2012; Ferri,
Nonpharmacological therapy:
ā¢ Lifestyle modifications and watchful waiting: nightly fluid restriction,
timed bladder voiding, double-voiding techniques, regular physical activity, pelvic floor exercises, treatment of constipation, and avoiding caffeine, alcohol, and highly seasoned/spicy or irritative foods (ACR, 2012; NCGC, 2014).
ā¢ Self-management programs (ACR, 2012; NCGC, 2014).
ā¢ Enroll in an exercise program commensurate with their ability to
perform these activities (ACR, 2012; NCGC, 2014).
ā¢ Personalized social (ACR, 2012; NCGC, 2014).
ā¢ Screen for an appropriately treat anxiety and depression (Ferri, 2016).
ā¢ Participate in cardiovascular (aerobic) and/or resistance land- based exercise
(ACR, 2012; NCGC, 2014).
ā¢ Manual therapy in combination with supervised exercise
(ACR, 2012; NCGC, 2014).
ā¢ If overweight (Mr. K is overweight) - lose weight: extra weight increases the
force on the hip with each step (ACR, 2012; NCGC, 2014).
ā¢ Wear medially wedged insoles for lateral compartment OA (ACR, 2012;
NCGC, 2014).
ā¢ Receive psychosocial interventions(ACR, 2012; NCGC, 2014;
Ferri, 2016)
ā¢ Receive walking aids, as needed disability (ACR, 2012; NCGC, 2
ā¢ Heat or cold therapy (NCGC, 2014).
ā¢ Rest: arthritis symptoms are typically worsened by activity and improved
with rest (Ferri, 2016). Health maintenance:
ā¢ Flu shot for Influenza prevention
ā¢ PVR-13 for pneumonia prevention
ā¢ Shingles vaccine for shingles prevention
ā¢ Tetanus shot single dose for prevention
ā¢ Preventative imaging testing include: colonoscopy for colon cancer
screening and yearly PSA Education Disease specific teaching for BPH and Osteoarthritis (Pearson, & Williams, 2014; Ferri, 2016).
Counsel patient to report symptoms of hepatotoxicity (eg. hepatitis, hepatic failure) (Sinusas, 2012; Ferri, 2016). Properly position and support your neck and back while sitting or sleeping (Sinusas, 2012; Ferri, 2016). Adjust furniture, such as raising a chair or toilet seat (Sinusas, 2012; Ferri,
Avoid repeated motions of the joint, especially frequent bending (Sinusas, 2012; Ferri, 2016). Follow up: Symptoms improve or stabilize in 70 - 80% of patients (ACR, 2012; Pearson, & Williams, 2014). Patient will be seen in 3 months to evaluate medication effectiveness (Symptom index (IPSS monitoring) or sooner if the patient's symptoms do not improve or get worse. Referral Patient should be referred to the urologist when there are strong indicators for surgery (urinary retention due to prostatic obstruction- obstructive uropathy, etc.) or if new and severe symptoms appear, or are current symptoms do not respond to medical management (AUA, 2012; Goroll, 2014). Refer to PT for eval and treat: education on self-management- specific exercises for range of motion, strengthening, or joint protection; gait training, pain management education, mobility aids; and education for dealing with functional difficulties (home, work or leisure) (ACR, 2012; Sinusas, 2012). References
American College of Rheumatology (2012). Recommendations for the Use of Non pharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research 64-4, 465-474. doi 10.1002/acr. American Urological Association (2012) AUA Releases guidelines on diagnosis and treatment of Overactive Bladder. American Family Physician. 2013 Jun 1; 87(11): 800-803. Retrieved from http://www.aafp.org/afp/2013/0601/p800.html Barr, A., & Conaghan, P. (2014). Osteoarthritis: recent advances in diagnosis and management. Prescriber , 25(21), 26-34. doi: 10.1002/psb.1271 View/save Barry, M. J., Fowler, F. J., O'leary, M. P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Measurement Committee of the American Urological Association (2017). The American Urological Association symptom index for benign prostatic hyperplasia. The Journal of urology, 197(2), S189 S197. doi:10.1016/j.juro.2016.10. Carter, H. B., Albertsen, P. C., Barry, M. J., Etzioni, R., Freedland, S. J., Greene, K. L., & Penson, D. F. (2013). Early detection of prostate cancer: AUA Guideline. The Journal of urology , 190(2), 419-426. doi: 10.1016/j.juro.2013.04. Christakos, S., Dhawan, P., Verstuyf, A., Verlinden, L., & Carmeliet, G. (2016). Vitamin D: metabolism, molecular mechanism of action, and pleiotropic effects. Physiological reviews , 96(1), 365-408. doi: 10.1152/physrev.00014.
Michels, T. C., & Sands, J. C. (2015). Dysuria: Evaluation and differential diagnosis in adults. American Family Physician , 92 (9), 778-788. Retrieved from http://www.aafp.org/afp/2015/1101/p778-s1.html National Clinical Guideline Centre (2014). Osteoarthritis care and management in adults. Retrieved from https://guideline.gov/summaries/summary/ Palmer, C. J., & Choi, J. M. (2017). Pathophysiology of Overactive Bladder: Current Understanding. Current Bladder Dysfunction Reports , 12(1), 74-79. doi: 10.1007/s11884-017- 0402-y Pearson, R., Williams, P. M. (2014). Common questions about the diagnosis and management of Benign Prostatic Hyperplasia. American Family Physician , 90(11):769-774. Retrieved from http://www.aafp.org/afp/2014/1201/p769.html Pluta, R. M., Lynm, C., & Golub, R. M. (2012). Prostatitis. Jama, 307(5), 527.doi:10.1001/jama.2011.2008 Sinusas, K. (2012). Osteoarthritis: diagnosis and treatment. American Family Physician, 85(1), 49-56. Retrieved from http://www.aafp.org/afp/2012/0101/p49.html
