New Urology Patient

CHIEF COMPLAINT: 1. Intermittent right flank pain 2. Increased urinary frequency and urgency 3. Concerns about erectile dysfunction HPI TODAY: 01 November 2024: Patient presents with a 3-month history of intermittent right flank pain, described as dull and aching, radiating to the groin. He reports increased urinary frequency (8-10 times/day) and nocturia (2-3 times/night) for the past 6 months, accompanied by a sense of urgency. No dysuria or haematuria reported. He also expresses concerns about erectile dysfunction, noting difficulty maintaining erections for the past year. Relevant history includes a prior episode of right renal colic 5 years ago, which resolved spontaneously. A recent CT KUB performed on 15 October 2024 at a private imaging centre revealed a 4mm non-obstructing calculus in the right lower pole kidney. I personally reviewed and independently interpreted the scan and agree with the findings. Urinalysis today shows no evidence of infection; PSA level is 1.8 ng/mL. Patient is a 55-year-old teacher, enjoying cycling as a hobby, which he reports has recently become uncomfortable due to groin discomfort. PMH, PSH, MEDS, ALLERGIES, SH, and FH: - Hypertension, well-controlled on medication. - Prior appendectomy 20 years ago. - Current chronic meds: Lisinopril 10mg daily. - Allergies: Penicillin (rash). - Social history: Non-smoker, occasional alcohol (2 units/week). Works as a secondary school teacher. Lives with spouse in a detached home. - Family history: Father had prostate cancer diagnosed at age 70. No family history of renal stones or hereditary conditions. PHYSICAL EXAMINATION: - Patient appears comfortable and is alert and oriented to person, place, and time (A&O x3). - Mood is euthymic, affect appropriate to content, insight appears good, judgment intact. - Abdomen is soft, non-tender. Right costovertebral angle tenderness present on percussion. No suprapubic tenderness. Genitalia exam unremarkable. Digital rectal examination reveals a benign, smooth prostate of normal size, non-tender. ASSESSMENT AND PLAN: Patient is a 55-year-old male presenting with right flank pain, bothersome lower urinary tract symptoms (LUTS), and erectile dysfunction. 1. Right Renal Calculus (N20.0) - Assessment: Stable 4mm non-obstructive right lower pole renal stone. - Plan: Conservative management with watchful waiting. Advised increased fluid intake to 2-3 litres per day. Arrange repeat KUB X-ray in 3 months. - Counselling: Discussed symptoms of acute renal colic, importance of hydration, and potential need for intervention if stone grows or becomes symptomatic. 2. Lower Urinary Tract Symptoms (LUTS) secondary to suspected Benign Prostatic Hyperplasia (BPH) (N40.1) - Assessment: Moderate LUTS, likely due to BPH, impacting quality of life. - Plan: Initiate Tamsulosin 0.4mg daily. Refer for Uroflowmetry and Post-Void Residual (PVR) assessment. - Counselling: Discussed potential side effects of Tamsulosin (e.g., dizziness, retrograde ejaculation) and importance of medication adherence. Provided lifestyle advice including limiting evening fluids and avoiding bladder irritants. 3. Erectile Dysfunction (N48.4) - Assessment: Patient reports moderate ED symptoms, possibly multifactorial given age and comorbidities. - Plan: Prescribe Tadalafil 5mg daily. Screen for cardiovascular risk factors. Provide lifestyle modification advice. - Counselling: Discussed expected benefits and potential side effects of Tadalafil. Advised on maintaining a healthy lifestyle, including regular exercise and balanced diet. ORDERS: - Labs: PSA, Creatinine (already done today) - Imaging: KUB X-ray in 3 months; Uroflowmetry and PVR - Prescriptions: Tamsulosin 0.4mg daily (30 days supply); Tadalafil 5mg daily (30 days supply) FOLLOW UP: Review in 6 weeks at district clinic to assess response to BPH treatment and Tadalafil, and to discuss Uroflowmetry/PVR results. SHORT SUMMARY: 55-year-old male teacher with right flank pain due to a 4mm renal calculus, LUTS, and ED. Plan includes conservative stone management, initiating Tamsulosin for BPH and Tadalafil for ED, and follow-up in 6 weeks.