Who you are:
An FY2 in General practice.Who the patient is:
75-year-old Steve Austin came to the hospital with some concerns.Additional Information:
He came to the clinic 2 weeks ago and was started on oxybutynin for stress incontinence. He used it for a week but that did not help, and the dose was doubled after a week. The patient has now booked an urgent appointment.What you should do:
Talk to the patient, assess, and address his concerns.
Presenting complaint (P1) (ODIPARA):
D: Hello Steve I am one of the doctors in general practice here. Is your full name Steve Austin.
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 75.
D: So, Steve, I can see that you have been having some concerns?
P: Yes, doctor, I was playing golf with my friend yesterday and I had a very odd sensation at that time, I don’t know what it was.
D: Tell me more about this sensation?
P: I don’t know but I felt a bit confused for a few moments and I didn’t know where I was or what I was doing. I have been having this feeling for a week now and I think it happened because of the drug I’ve been put on.
D: Can you tell me about the drug, what drug is it and why are you taking it?
P: 2 weeks ago I went to the doctor as I was going to the loo more often and it was very difficult for me to hold my urine in. I was prescribed oxybutynin 2 weeks ago, but the symptoms did not go away, so my dose was doubled a week ago.
D: Did your symptoms improve after doubling the dose?
P: Yes doctor, they did improve but then this happened and I stopped taking it yesterday.
D: Do you have any other symptoms apart from the confusion?
P: No.
D: Any fever?
P: No.
D: Any changes in your urine (cloudy, frothy, blood)?
P: No.
D: Any nausea and vomiting?
P: No.
D: Do you have any pain while passing urine?
P: No.
D: Do you have to go to the loo more frequently at night?
P: Yes.
D: How many times do you have to wake up during the night?
P: Twice, I think.
D: Any other problems with urinating, like straining or having difficulty in passing urine or dribbling at the end?
P: No, doctor.
D: Are you able to hold your urine before going to the loo?
P: Well, that was the problem that I went to the doctor in the first place about and it improved since I doubled the dose of medicine.
D: Do you feel like you are not able to completely empty your bladder?
P: No
D: Have you noticed any weight loss?
P: No doctor.
D: Any lumps and bumps anywhere?
P: No, doctor.
D: Any changes in appetite?
P: No.
Concern
D: Apart from this, is there anything else that’s concerning you?
P: Well, being confused was scary.
D: I can imagine it was.
Past medical conditions (P2)
D: Has this ever happened before?
P: No.
D: Do you have any medical conditions that I should be aware of?
P: Just this problem with the urine, nothing else.
D.E.S.A (P3) + Sexual history:
D: Are you physically active?
P: I try to be physically active, doctor.
D: Do you smoke?
P: No, doctor.
D: What about alcohol?
P: No, doctor.
M.A.F.T.O.S.A
D: Are you on any long-term medication apart from oxybutynin?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.
Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.
Examination:
â—Ź Observation (Check vitals + BMI)
â—Ź Abdominal Examination
â—Ź Per rectal examination
Provisional diagnosis:
Steve, from what you told me, I understand that you had a feeling of being confused yesterday and you have been having this urge incontinence problem for which you have been taking oxybutynin with a double dose since last week. I suspect that you are correct in thinking this was caused by doubling the drug dose, as it is a known side effect of this drug.
Management:
Refer: Specialist referral to review the medication and dosage.
Involve senior.
Investigations:
- FBC, RFT, LFT, U&E
- Urine dipstick
Symptomatic management:
- Lifestyle modifications including reducing caffeine, drinking an optimal amount of water, losing weight, to counter the incontinence problem to decrease the drug dosage.
- Pelvic floor muscle training (Kegel exercises)
- Bladder training.
- NHS incontinence services which include special nurses and physiotherapists who can help with the issue.
Surgical management:
- Urge Incontinence: Botulinum toxin A injection, Sacral nerve stimulation.
Specialist:
Refer to the specialist for medication review and further management of urge incontinence.
Safety-net
- If symptoms are worsening
- If you are not feeling yourself.
- UTI (lethargic/ drowsy/ tired)
- Pyelonephritis (loin pain/ fever & chills/ vomiting)