To PR or not to PR…
A few weeks ago, my uni students were given a scenario similar to this one:
Mr Hugh Jass, 65 year old lawyer presents with headache, nausea and sweatiness. Cough, non productive. Muscle aches, dysuria and urinary frequency. No symptoms of meningism. 25 year pack history. No other relevant family or past history.
O/E: Temp 40C, HR 90, BP 110/90, RR 18. Crackles in right base. Abdo tender suprpubically, no loin tenderness. BS normal.
In the case, Hugh is referred to a tertiary ED where he has some tests. CXR shows some COPD but no consolidation and urine grows E.coli. He is evenutally seen by a urology consultant who gets a better LUTS history and does the PR and PSA test.
The question was asked, quite fairly, should we have done a PR earlier? And if so, when? GP room, first ED work up? It made me wonder “would I have done a PR in the GP room for this man?”
I also put myself out on a limb during the case conference with the other tutors and said that I probably wouldn’t have sent this man to ED. Was almost shouted down! I thought that a reasonable action (even in the peri-urban setting) may have been to check for UTI with dipstick and commence on oral antibiotics. Given his high fever and symptoms perhaps even a shot of IV antibiotics as a stat dose? Although I understand that a UTI in a male is a concern, I thought immediate referral to ED was a tad overzealous. Of course more detailed history about urinary symptoms, DRE, PSA (if symptomatic) and a referral to urology would be on the cards, but within a week or so. It seemed from the other tutors that this would be too gung-ho….
Interested for your thoughts.