S:

MM is an 80 yo male with chief complaint of “blood in my Foley bag.” He noticed the frank blood at 4AM this morning. This is the first occurrence. Catheter was changed 2 weeks ago. He states he strained while having a bowel movement last night. Patient states his PSA is elevated and he is scheduled for a prostate biopsy next week. Admits unintentional 5lb. weight loss in 1 month. Denies fever, chills, fatigue, abdominal pain, penile pain, testicular pain or masses, cloudy urine, flank pain, confusion.

PMH: BPH, Atrial Fibrillation, HTN, Constipation, Hemorrhoids, Emphysema

PSH: Dental Bridge Procedure 1.5 months ago, Umbilical Hernia Repair

Allergies: NKDA

Medications: Warfarin (Coumadin) 5mg PO qd, Digoxin 250mcg PO qd, Metoprolol 50mg PO bid, Tamsulosin (Flomax) 0.4mg PO qd

FHx: Unknown

SHx: 43 pack-year smoking history from ages 12-55 yo when he quit; Occasional EtOH use 1-2 glasses of wine/week

O:

T 97.8°F | BP 122/78mmHg | P 80 BPM, regular | RR 14 breaths/min, unlabored | SpO2 94% RA

H 70in | W 180 lb. | BMI 25.8

Gen: Neatly groomed and in no apparent distress. Looks his stated age. Alert and cooperative.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Abd: Flat, symmetrical. No scars, striae, caput medusa. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. Nontender to light/deep palpation throughout. No guarding or rebound, CVAT, organomegaly.

GU: Circumcised male with catheter in place. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally. Epididymis nontender. Frank blood with clots observed in Foley leg bag.

A:

80 yo male with hematuria noted in Foley bag x 1 day, history of BPH, elevated PSA, and prostate biopsy scheduled next week. Likely prostate cancer.

Differential Diagnosis:

1. Prostate Cancer
2. Trauma (Straining with a Foley catheter in coupled with the patient’s BPH)
3. Bladder Cancer
4. Arteriovenous Malformation
5. Medication Side Effect (Excess Anticoagulation)
6. Renal Cell Cancer

P:

Labs:

• CBC
• Coagulation Studies (PT/INR, PTT)
• U/A, Urine Culture

 

Prostate Cancer versus BPH:

• Change Foley leg bag and repeat U/A, Urine Culture. Assess for gross blood.
• Urology consult
• Patient scheduled for prostate biopsy next week with Dr. Wong

Atrial Fibrillation:

• Continue Warfarin (Coumadin) 5mg PO qd
• Continue Digoxin 250mcg PO qd

HTN:

• Continue Metoprolol 50mg PO bid

Constipation/Hemorrhoids:

• Follow up with PMD

Emphysema:

• Follow up with PMD

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

Traumatic Catheterization                                          Prostate Cancer

UTI                                                                              Trauma (Straining…)

Prostatitis                                                                   Bladder Cancer

Epididymitis                                                                Arteriovenous Malformation

Coagulopathy or excess anticoagulation                   Medication Side Effect (Excess AC)

Urolithiasis                                                                 Renal Cell Cancer

Prostate Cancer

Bladder Cancer

Renal Cell Cancer

BPH

Trauma

Arteriovenous Malformation

Medication Side Effect (e.g. rifampin, etc.)

Food Side Effect (e.g. Beets, etc.)