Mock Patient Script – Abnormal Urination

Case 1 – “I sat through a movie and couldn’t pee at all.”

Doorway Information

• Age: 72
• Gender: Male
• Chief Complaint: Unable to urinate after sitting in a theater
• Vital Signs: T 36.8℃, HR 86, BP 138/84, RR 16, SpO₂ 98%

Opening

“I went to see a movie with my granddaughter, but after it ended, I just couldn’t pee.”

Shoreline

He reports that he had been experiencing slower urine stream and frequent nighttime urination for months, but this is the first time he was unable to void entirely.

Structured History

Onset & Course

Symptoms began acutely after sitting for over 2 hours. He had been drinking soda during the movie. The urgency became unbearable, but no urine was passed.

Associated Symptoms

Lower abdominal discomfort and restlessness. No flank pain, fever, or hematuria.

Mood / Function / Appetite / Sleep

Generally active, enjoys retirement. Poor sleep due to nocturia. Appetite normal.

PAM HITS FOSS

• Previous & Past Medical History: Hypertension, mild osteoarthritis
• Allergy: None
• Medication: Amlodipine, occasional NSAIDs
• Hospitalization: None recent
• Injury: None
• Trauma: None
• Surgery: Appendectomy (childhood)
• Family History: Father had prostate issues
• OBGYN: Not applicable
• Sexual History: Monogamous, no concerns
• Social History: Lives with wife, non-smoker
• Substance Use: Drinks alcohol socially, no drugs

Physical Examination

• General: Alert, visibly uncomfortable
• Abdomen: Distended, suprapubic tenderness, dull to percussion
• GU: External genitalia normal, no discharge or lesions
• Neuro: No focal deficits

Differential Diagnosis

• Most Likely: BPH with acute urinary retention
  Slowed stream, nocturia, prostate history, bladder distension
• 2nd: Urethral stricture
  Unlikely without prior instrumentation or infection
• 3rd: Medication-induced urinary retention
  No anticholinergic meds

Clinical Reflection

His history of progressive lower urinary tract symptoms and sudden inability to void points toward BPH leading to bladder outlet obstruction.

Clinical Tips

• Nocturia in older men often signals BPH—ask early.
• NSAIDs can worsen urinary retention in predisposed individuals.
• Always palpate and percuss the bladder in suspected retention.

Challenging Questions

Q: “Do I need surgery?”
A: “Not necessarily. Many cases improve with medications. First, we’ll insert a catheter to relieve the pressure, then evaluate your prostate size and symptoms to guide the next steps.”

Q: “Will this happen again?”
A: “It’s possible, especially without treatment. But now that we know what’s happening, we can manage it and reduce the risk going forward.”

📝 SOAP Note

S: 72M with acute urinary retention after a movie. Gradual LUTS for months: nocturia, weak stream. Suprapubic pressure, no fever/flank pain.

O: T 36.8℃, HR 86. BP 138/84. Abdomen: distended, suprapubic tenderness. GU: no lesions. Neuro: intact.

A:
# Acute urinary retention
# Chronic LUTS suggesting BPH
ddx): BPH, urethral stricture, neurogenic bladder
r/o): Infection, medication-induced retention

→ Most likely due to BPH. Will place Foley, initiate alpha-blocker, evaluate with bladder scan and PSA.

P:
- Foley catheter insertion
- Tamsulosin 0.4 mg daily
- Bladder ultrasound
- Schedule urology consult
  

Case 2 – “I leak urine but never feel the urge.”

Doorway Information

• Age: 58
• Gender: Male
• Chief Complaint: Urinary leakage without warning
• Vital Signs: T 36.5℃, HR 78, BP 126/80, RR 16, SpO₂ 97%

Opening

“My pants get wet before I even realize I needed to go.”

Shoreline

He noticed gradual dribbling over 3–4 months and wetness in underwear. No pain or urgency.

Structured History

Onset & Course

Started gradually. Now leaks 2–3 times daily. Never feels bladder full.

Associated Symptoms

Also reports numbness in feet. Constipation. No dysuria or hematuria.

Mood / Function / Appetite / Sleep

Fatigued from disrupted sleep and discomfort. Eats less due to worry.

PAM HITS FOSS

• Previous & Past Medical History: Diabetes (15 years)
• Allergy: None known
• Medication: Metformin, insulin
• Hospitalization: For foot ulcer last year
• Injury: None
• Trauma: None
• Surgery: None
• Family History: Mother had diabetes
• OBGYN: Not applicable
• Sexual History: Erectile dysfunction noted
• Social History: Lives alone, retired mechanic
• Substance Use: Smokes 10 cig/day, drinks occasionally

Physical Examination

• General: Mildly anxious, cooperative
• Abdomen: Soft, non-tender, bladder palpable
• GU: Normal penis/testes, no discharge
• Neuro: Decreased ankle reflexes, decreased vibration in feet, reduced perianal sensation

Differential Diagnosis

• Most Likely: Diabetic autonomic neuropathy with neurogenic bladder
  Chronic DM, sensory loss, overflow pattern, absent urge
• 2nd: Spinal cord compression
  Needs exclusion (no back pain, no trauma)
• 3rd: Prostate cancer
  Unlikely without weight loss, hematuria, nodules

Clinical Reflection

His classic diabetic neuropathy signs plus large post-void residual strongly suggest neurogenic bladder due to autonomic dysfunction.

Clinical Tips

• Ask about bladder sensation—key in differentiating urge vs overflow.
• Bladder scan is essential in incontinence eval.
• Diabetics may present with “silent” neurogenic bladder.

Challenging Questions

Q: “Is this permanent?”
A: “The nerve damage may not fully reverse, but we can manage the symptoms. There are devices, medications, and strategies to help you stay dry.”

Q: “Is this a sign of kidney failure?”
A: “Not directly, but unmanaged retention can affect the kidneys. That’s why timely diagnosis and management are important.”

📝 SOAP Note

S: 58M with progressive urinary leakage without urge sensation. Long-standing DM, numb feet, constipation. Erectile dysfunction.

O: T 36.5℃, HR 78. Abdomen: bladder palpable. Neuro: decreased sensation, reflexes, perianal hypoesthesia.

A:
# Urinary incontinence – likely overflow
# Diabetic autonomic neuropathy
ddx): Neurogenic bladder, spinal lesion, prostate cancer
r/o): No back trauma, normal rectal tone

→ Findings consistent with neurogenic bladder due to diabetic neuropathy. Will confirm with post-void residual and neuro referral.

P:
- Bladder ultrasound
- Initiate clean intermittent catheterization
- Refer to urology and neurology
- Adjust diabetic regimen
  

References

• AUA Guidelines on BPH, 2021
• UpToDate: Evaluation of urinary retention
• J Clin Endocrinol Metab. Diabetic autonomic neuropathy. 2022
• ICS Report on LUT dysfunction, 2017

Recommended Resources

• First Aid for the USMLE Step 2 CS
• ダ・ヴィンチのカルテ：診断推論99症例
• ティアニー先生の臨床入門
• OET公式教材