SAMPLE CASE REPORT

By Dr. Leulseged Damene

DMU, Debremarkos Referal Hospital

For PHO students

This sample case report is on an imaginary patient, Ato. Barack Obama, a 65 years old male
patient who presented with urinary symptoms.
The aim of this particular piece of writing is to help PHO students who have started clinical
practice/ attachment with the way they take history and give an example on how to build history
to reach at a possible diagnosis.
It is also better to report cases in occasions like bedsides, rounds and practical oral exams in the
following manner because it is more interesting.
The general approach to build your HPI is sampled in the following history. Try to use it as a
guide, and remember; every case has its own details. The following is a case of BPH.

Those words and sentences in bold letters are not to be reported. They are put there to guide
you.

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HISTORY

1. IDENTIFICATION
NAME: Barack Obama
AGE: 65 years
SEX: Male
ADDRESS: Lumame, East Gojam Zone
OCCUPATION: Farmer
RELIGION: Muslim
MARITAL STATUS: married
DATE OF ADMISSION: 23/7/09 E.C
HOSPITAL: Debremarkos Referal Hospital
Ward: Surgery
BED NUMBER: 24
.
***A better way to present Identification is like the following

This is Ato (N)Barack Obama, a (A)65 years old (S)male patient from (AD) Lumame, east
Gojam.
He is (O) Farmer by occupation and (R)Muslim by religion; and is (M)married and father of 2
children.
He was admitted on(DOA) Saturday, 23/7/2009 E.c at 4:00 morning local time to
(H)Debremarkos Referal Hospital, (W)Surgical side, Bed No. 24.
Source of history was the patient.

2. PREVIOUS ADMISSIONS:
 He was admitted on 2008 E.C. at Lumame primary hospital in Lumame, for acute
urinary retention; he was catheterized and was given PO medications and discharged
improved.

3. CHIEF COMPLIANT:
 Difficulty of urination of 1 year and 6 months duration
(Think all the possible differentials for difficulty of urination at this stage
Like BPH, Prostatic cancer, urethral stricture, neurogenic bladder etc.)

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4. HISTORY OF PRESENT ILLNESS:

In 1st paragraph, characterize the chief compliant (OPQRST)

This is a 65 years old male patient, who was relatively healthy until 1 year and 6 months back
at which time he started to experience difficulty of urination. The difficulty has a gradual onset
and a persistent course and it is not improved by straining.
(Note: most of the time you should be able to think of the top possible differentials after characterizing your
chief compliant)
In 2nd paragraph, list associated symptoms
It was associated with poor flow of urine. He also has intermittent stream, feeling of
incomplete voiding and dribbling. He has a frequency of day to night ratio of 5/8 and urgency
which is accompanied by urge incontinence. He is awakened by the urge to void about 8 or more
times at night. The patient almost always experiences all the above symptoms.
One year and 6 monthes back he developed acute urinary retention suddenly and he was
catheterized at Lumame hospital for 2 weeks. He was on intermittent catheterizations for the last
one year and 3 months following the episode of acute urinary retention. He had haematuria for 9
days during this same time. This treatment gave the patient a temporary relief but the symptoms
didn’t go away.
from the HPI upto this point, it looks like Ato Obama has BPH. But we are not sure yet;
so..
In 3rd paragraph, Negative/ Positive statements
(In this part of your HPI, try to confirm the presence or absence of your top differentials which shouldn’t be
more than 3 or 4 by now.)
Otherwise, he has no history of
1. Could it be BPH/ Prostatic Ca??? if it is, is it advanced???
(in addition to age, look for additional symptoms and risks)
 Loin or suprapubic pain
 Loss of appetite, nausea, vomiting, weight loss
 Bone pain, perineal heaviness, dragging pain or discomfort
 Alcohol ingestion or smoking
 Back pain, easy fatigability or tinnitus ,swelling of the body or the legs, light headedness
or palpitation
 chest pain or shortness of breath
 Yellowish discoloration of the eyes and skin

2. Could it be urethral stricture???

(dig for risks to develop stricture like STI, repeated catheterization, perineal trauma etc)
 Gonorrhea or other STD’s
 Previous surgery or trauma to the genitourinary tract
 Urethral discharge
3. Could it be urinary stones and their complication???
 Pain in the groins, testicles, tip of penis or medial side of the thigh
 Pain during urination or burning sensation
 Fever, chills, rigors

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 4. Could it be neurogenic bladder???
 Hypertention or diabetes mellitus
 Family history of Alhimer’s or Prkinson’s disease
 Headache, seizures or loss of consciousness
 Trauma to the back, neck or spinal cord injury

In 4th paragraph, include miscellaneous history

 TB, chronic cough or contact with a known TB patient or a chronic cougher
 Personal or family history of hypertention, DM, asthma, TB, allergies or cardiac illnesses
 Family hx of similar disease
 Mode of transportation(ambulance/ public bus/ walking/ carried by others etc)

5. PAST ILLNESSES
 He had malaria when he was 8 years old and was treated
 He had no other medical or surgical illness previously.

6. FUNCTIONAL INQUIRY

H.E.E.N.T
HEAD:
 no headache or head injury
EARS:
 no loss of hearing or discharge
EYES:
 good vision
 no pain, excessive lacrimation or photophobia
NOSE:
 no abnormal discharge or epistaxis
MOUTH AND THROAT:
 no bleeding gums, sore throat or sore tongue
 no tonsillectomy or difficulty of swallowing
LYMPHOGLANDULAR SYSTEM:
 no enlarged accessible lymphnodes
 no thyroid enlargement
RESPIRATORY SYSTEM:
 no cough, expectoration, haemoptysis, chest pain, shortness of breath, asthma or cyanosis
CARDIVASCULAR SYSTEM:
 has no palpitation, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, syncope or easy
fatiguability.
GASTROINTESTINAL SYSTEM:
 good appetite, no nausea or vomiting
 has normal bowel habit and no bloody, tary or clay colored stool
 no yellowish discoloration of sclera or hemmoroids
GENITOURINARY SYSTEM:
 see HPI

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INTEGUMENTARY SYSTEM:
 no rashes or ulcers, normal hair distribution, no pigmentary or fingernail changes, no
varicose veins
ALLERGY:
 no sensitivity to any drugs
LOCOMOTOR SYSTEM:
 no bony deformities, joint pain or swelling
 no limping or loss of function of limbs or joints
 no muscle weakness or wasting
CENTRAL NERVOUS SYSTEM:
 good memory, no loss of consciousness, lack of orientation, seizure, vertigo, diplopia or
insomnia
 7. PERSONAL HISTORY
He was born in Lumame and spent his whole life there. He was educated upto the level of
9th grade and. and he worked as a farmer for the past 35 years. He lives in a three room
house with his 2 daughthers. They have a toilet and a clean water supply. He has no
history of any drug abuse or any addictions.

8. FAMILY HISTORY
 His parents died at old age without any known cause. He has 2 sisters who are alive and
healthy and he had a brother who died 3 years back due to an unknown disease There is
no family history of hypertension, diabetes mellitus, cardiac illness, asthma or TB.

PHYSICAL EXAMINATION

GENERAL APEARANCE:
 healthy looking and moderately nourished
 conscious and not in cardio-respiratory distress
 looks comfortable
VITAL SIGNS:
 T : 36.8 c ,axillary
 PR: 92 beats per minute, from right radial artery, regular and full in volume
 RR: 20 breaths per minute, regular
 BP: 110/70 mmHg, right arm, sitting position

H.E.E.N.T:
HEAD:
 Normal size and shape
 Normal hair distribution
EARS:
 clear external canal, no discharge or mastoid tenderness
 good and equal hearing

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EYES:
 no periorbital edema, ptosis, exophthalmos, strabismus or lid lag
 pink conjunctiva and white sclera
NOSE:
 central nasal septum, no polyp or discharge
MOUTH AND THROAT:
 no fissures or ulcerations on the lips
 wet buccal mucosa
 gums are intact and clean

GLANDS:

Lymphatic Glands:
 no enlargement of all accessible lymph nodes and glands, i.e. pre-auricular, post-
auricular, occipital, submental, submandibular, cervical, supraclavicular, infra-
clavicular, axillary, epi-trochlear, popliteal or inguinal areas.
 Thyroid is not enlarged or tender, does not move with respiration, there is no
pulsation or bruit over it

RESPIRATORY SYSTEM:

Inspection:
 no cyanosis of lips or clubbing of fingers
 normal rate and depth of respiration
 chest wall is symmetrical and no chest wall deformity
 no use of accessory muscles and no chest wall retractions

Palpation:
 central trachea
 normal and comparable tactile fremitus
 symmetrical chest wall expansion

Percussion
 the chest is resonant on percussion
 diaphragmatic excursion is 3 c.m.
Auscultation
 vesicular breath sounds over the lung fields.
 no adventitious sounds or friction rub

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CARDIOVASCULAR SYSTEM:
Arteries:
 all accessible arterial pulses are regular and full in volume and are symmetrically
palpable over the carotid, brachial, radial, femoral, popliteal, dorsalis pedis and
posterior tibialis
 no radio-femoral delay
Veins:
 no distended veins over the neck, chest, abdomen or extremities
 JVP is not raised
Precordium:
Inspection:
 Quiet precordium, no bulging
Palpation:
 PMI is on the 5th intercostals space just medial to the mid-clavicular line
 No thrill or heave
 P2 is not palpable

Auscultation:
 S1 and S2 are heard well with normal intensity over all valvular areas
 No gallop, murmur or friction rub

GASTROINTESTINAL SYSTEM:

Inspection:
 Symmetrical
 Flat abdomen
 Flanks are not full
 Inverted umbilicus
 Abdomen moves with respiration
 No scars or distended veins
 No visible perstalitic movement or pulsation of the abdominal aorta

Palpation:
Superficial:
 No superficial tenderness or any superficially palpable mass
 No guarding, rigidity or abdominal wall defect

Deep:
 No deep tenderness
 There is no deeply palpable mass
 The liver, the spleen and the kidneys are not palpable
Percussion:
 Abdomen is tympanitic to percussion
 No shifting dullness or fluid thrill
 Total liver span is 11.5c.m.

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 Auscultation:
 Normal bowel sounds
 No bruits or friction rub over the liver and the spleen
 No bruit over the abdominal aorta
DRE:
Inspection:
 No skin rashes and excoriation
 No discharge or blood visible
 No scars or fistula
 No polyp or prolapse
Palpation
 No tenderness
 Normal tone of anal sphincter
 Mobile rectal mucosa
 Median sulcus of prostate is palpable
 Surface of prostate is smooth
 Prostate is enlarged but size couldn’t be measured
GENITOURINARY SYSTEM:
 there is no costo-vertebral angle or supra-pubic tenderness
 no flank mass

Penis- Inspection - no scars, no prepuse

- no scars or nodules in the glans
Palpation -no tenderness or indurations along the shaft of the penis
Scrotum- Inspection – no swellings or scars
INTEGUMENTARY SYSTEM:
 the skin is warm and there is no rash, ulcers, edema, varicose veins or spider angiomas
 no hypo or hyper pigmentations
 normal hair distribution
 no spooning or color change of the nails or palmar erythema is present
LOCOMOTOR SYSTEM:
 normal gait
 no muscle tenderness or spasm
 no joint swelling, tenderness, redness, limitation of movement or deformity
 no bone fractures, deformity, periosteal thickening or tenderness
 normal joints and no bone deformity
CENTRAL NERVOUS SYSTEM:
 he is oriented to person, place and time
 he has good memory and mood
 he doesn’t have hallucinations or delusions
CRANIAL NERVES:
 are all intact

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MOTOR FUNCTIONS
 comparable muscle bulk, no atrophy
 no spontaneous or induced fasciculations
 normal muscular tone and power
SENSORY FUNCTION
 light touch and pain sensations are intact
 pain, pressure and position sensations are intact
COORDINATION
 finger to nose, finger to finger and rapid alternating movement tests are normal

REFLEXES

Superficial
 normal corneal, abdominal and plantar reflexes

Deep tendon reflexes

 normal biceps, triceps, brachioradialis, patellar and ankle reflexes
 there is no clonus

Meningeal signs
 both Brudnzki’s and Kernig’s signs are negative

Assesment:- Bladder outlet obstruction(BOO) secondary

to BPH ? R/o Prostatic ca

Plan:- See end of page.

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SUMMARY
Subjective(From History)
This is a 56 years old male patient who presented with difficulty of urination of one and half
years duration. He also complains of poor stream, dribbling, feeling of incomplete voiding,
frequency (d/n=5/8) and urge incontinence. And he has a history of hematuria and repeated
catheterization.

Objective(From P/E)
He is healthy looking, moderately nourished and was sitting comfortably on his bed. He was not
in cardiorespiratory distress and his vital signs were stable. He has no signs of dehydration and
anemia. Mobile rectal mucosa, palpable median sulcus of prostate and enlarged prostate with
smooth surface.

DIFFERENTIAL DIAGNOSIS

1. BOO secondary to BPH

2. BOO secondary to prostatic ca
3. BOO secondary to urethral stricture

DISCUSSION OF DIFFERENTIALS

3. BOO secondary to urethral stricture

Supportive Against
-obstructive and irritative symptoms - no hx of STD
-hx of repeated catheterization - no hx of urethral trauma
- no hx of GUS surgeries
- no hx of TB
- no hx of dysuria
- on PE, no induration along the
ventral surface of the penis

2. BOO secondary to prostatic ca

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Supportive Against
-age - no pelvic pain
-symptoms of BOO - no bone pain, malaise or signs of
- haematuria anemia
- and on PE- prostate is not nodular,
median sulcus is palpable and
the rectal mucosa is mobile

1. BOO secondary to BPH

Supportive

-BOO symptoms
-age
-hematuria
-PR – median sulcus is palpable
- smooth surface of enlarged prostate
- mobile rectal mucosa
- hx of acute urinary retention

Against
- No symptoms of complicated BPH, such as; renal failure, UTI, diverticuli, and
stones, but this is not enough to rule out this differential since most of the signs
and symptoms are suggestive of BPH.

 Therefore, the most possible diagnosis is BPH

***After this, you have to do investigations

Investigations
Baseline Diagnostic
-CBC with blood group and RH -uroflowmetry
-LFT -ultrasound
-RFT -serum PSA
-FBS -urethroscopy
-U/A -ascending urthrogram
-ECG -micturating urethrogram
-transrectal trucut biopsy
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 -bone x-ray
-serum alkaline phosphatase
- CT and MRI scan

Management

Medical treatment
- Alpha adrenergic agonists
- 5 alpha reductase inhibitors

Surgical treatment
-transurethral resection of the prostate
-open retro-pubic prostatectomy
- transurethral incision of the prostate
- bladder neck incision
- laser prostatectomy
- microwave thermotherapy ablasion of the prostate

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