5 Geriatric populations and males health 9 ..

2559
09.00-12.00 .

1.

2.

1.
2.

(Erectile Dysfunction: ED)
CC: Ive been having some problems, you know, in the bedroom.
HPI : Jack Johnson is a 65-year-old man. On questioning, he states that for the last year
he has been able to achieve only partial erections that are insufficient for intercourse.
He does not notice nocturnal penile tumescence. He feels that the problem is leading
to a strained relationship with his wife.
PMH :
- Type2DM 10years - HTN
- Dyslipidemia
SH : Married for 32 years; no history of marital problems. He is a non-smoker and
drinks two to three alcoholic beverages per week. Walks for 30 minutes 5 days/wk
without significant SOB.
FH : Father deceased at age 72 of cancer; mother alive with HTN Drug allergy : NKDA
Meds:
Glibenclamide 5 mg po once daily
Metformin 500 mg po BID
Lisinopril 40 mg po once daily
Carvedilol 25 mg po BID
Simvastatin 40 mg po once daily ASA 81 mg po once daily
ROS: Denies significant life stressors, fatigue, nocturia, urgency, or symptoms of
prostatitis. Complains of some numbness in his feet and difficulty achieving and
maintaining erections.
PE:
Vital sign : BP 122/76, P 60, RR 18, T 37.2C; Wt 80 kg, Ht 160 cm GA : Alert, welldeveloped, cooperative man
Labs:
Urinalysis
HEENT : NC/AT; EOMI; PERRLA; funduscopic examination shows no arteriolar
narrowing, hemorrhages, or exudates
Skin: Warm, dry; no lesions
Neck/LN : Supple without JVD, lymphadenopathy, masses, or goiter
Heart : regular, normal sinus rhythm, no murmur
Lung : Clear; no rales or rhonchi
Abd: Soft, obese; NTND; normal bowel sounds; no masses or organomegaly
Genit/Rect: Normal scrotum, testes descended; penis without discharge or curvature
MS/Ext: Muscle strength 5/5 throughout; full ROM in all extremities; pulses 2+
throughout; no edema present; multiple toenails with yellow discoloration and
thickening

Neuro: CNs IIXII intact; DTRs 2+ and equal bilaterally. No sensory/motor deficits;
reduced sensation in extremities bilaterally with vibratory and monofilament testing
Hgb 16.0 g/dL Hct 50%
CO2 24 mEq/L SCr 1.0 mg/dL TG 96 mg/dL
Na 139 mEq/L
K 3.9 mEq/L
Cl 102 mEq/L
BUN 12 mg/dL
Glu (fasting) 200 mg/dL
Ca 9.5 mg/dL
Mg 1.8 mEq/L
A1C 9.5%
LDL 86 mg/dL Testosterone 700 ng/dL
Fasting Lipid Profile: T. chol 153 mg/dL HDL 48 mg/dL VLDL 19 mg/dL
SG 1.00; pH 5.1; leukocyte esterase (); nitrite (); protein 100 mg/dL; ketones ();
urobilinogen normal; bilirubin (); blood ()
Problem list
1. Erectile dysfunction
2. Poor long-term control of Type 2 DM
3. Hypertension controlled on current therapy
4. Dyslipidemia controlled on current therapy
5. Probable diagnosis of onychomycosis
Questions
1. Drug Therapy Problems
Lisinopril Corvedilol ADR Genitourinary disease : Impotence

2. ED

Cardiovascular disease
DM
BPH
Drug induced ED
Stress,anxiety,depression
Urologic surgery
smoking

65

DM type II 10

3. ED

Vascular Artherosclerosis,Penile Raynauds
phenomenon
Neurologic Cerebrovascular accident,Spinal cord damage,
autonomic neuropathy,Peripheral neuropathy

 Endocrine
DM,Hypergonadism,Prolactinoma,Hyperthyroidism,Hypothyroidism
Iatrogenic Pelvic radiation,lumbar
sympathectomy,Prostatectomy,renal transplantation,Spinal cord resection
Psychogenic Stress,Depression

Uncontrolled DM neurologic symptom

Peripheral neuropathy , Medication induce ED : Lisinopril,Carvedilol
4.

5. ED

ED

1.Drug induced ED :

2.Psychogenic ED : Psychotherapy
3.Organic ED : Specific treatments
: oral Phosphodiesterase inhibitor inhibitor
Vacuum erection device :

Intracavenasal therapy : PDEI IV Carvenasal

Penile prosthesis : Intracavenasal therapy
6. (non-pharmacologic alternatives)
Vacuum erection device Penile prosthesis

7.
(list
the drug, dosage form, dose, schedule, duration of therapy)
PDEI Sidenafil 25 mg 1 tab Before activity at
least 1 hr dose
5-8 dose

8. Efficacy monitoring parameter ADR monitoring parameter

Efficacy monitoring : erection

1-3
ADR Monitoring : Vacuum erection device : cool to touch,discolor,pain
Sidenafil : Headache ,Facial flushing,Dyspepsia
9. Self-study assignments

Sidenafil
5-8 dose

10. (onychomycosis)

Terbinafine 200 mg/day 12 (2nd line)

1st line Itraconazole gwfh gonjv0kdgdbf DI CYP3A4 Sidenafil

(Benign Prostatic Hyperplasia:

BPH)

CC: I cant sleep at night. Im up four or five times feeling that I have to urinate, and
then when I get to the bathroom all I do is dribble. Sometimes I dont even make it to
the bathroom in time. I have a girlfriend now and I regularly take Cialis. Going to the
bathroom all night is really impacting my love life.
HPI : Conrad McLaren is a 62-year-old man with a longstanding history of UTIs. He has
been hospitalized twice in the past 3 years for urosepsis. He is being evaluated
because of complaints of worsening urinary hesitancy, nocturia, and dribbling
PMH :
- HTN
- BPH with urge incontinence
- Chronic UTIs
- Type 2 DM (well-controlled with
Glibenclamide/metformin)
- Erectile dysfunction
- Obesity
- Hx headaches
SH : Used smokeless tobacco 35 years; heavy ETOH in the past, occasional glass of
wine now.
FH : Father died of MI at age 72; mother died of natural causes at age 91 Drug
allergy : NKDA
Meds:
Glibenclamide 5 mg po once daily
Amitriptyline 50 mg po at bedtime (H/A
prophylaxis)
Metformin 500 mg po BID Lisinopril/hydrochlorothiazide 10/12.5 mg po once daily
Tadalafil 10 mg po PRN
PE:
Vital sign : BP 140/95, P 72, RR 18, T 37C; Wt 115.2 kg, Ht 180 cm
GA : White male; well-kept appearance; well-developed
HEENT : PERRLA; EOMI; TMs WNL; nose and throat clear w/o exudate or lesions
Skin: Warm, dry; no lesions
Neck/LN : Supple w/o LAD or masses; thyroid in midline
Heart : regular, normal sinus rhythm, no murmur
Lung : Clear; no rales or rhonchi
Abd: Soft, NTND w/o masses or scars; (+) BS
Genit/Rect: DRE; prostate enlargement with symmetry and rubbery, penis circumcised
w/o DC MS/Ext: Neurovascular intact; distal pulses 12+
Neuro: DTRs 2+; CNs IIXII grossly intact
Labs:
Na 136 mEq/L
CO2 41 mEq/L
Urinalysis

K 4.1 mEq/L
BUN 9 mg/dL

Cl 103 mEq/L mg/dL

SCr 0.7 mg/dL

Hgb 12.6 g/dL

Hct 37.9%
MCV 92.5 m3
MCH 30.8 pg
MCHC 33.3 g/dL
Plt 191 103/mm3
WBC 5.6 103/mm3 Neutros 75%
Lymphs 16%
Monos 5% Eos 3%
Basos 1%
AST 12 IU/L
ALT 16 IU/L
Alk Phos 55 IU/L
LDH 121 U/L
T. bili 0.6 mg/dL
T. prot 6.1 g/dL
Ca 8.5 mg/dL Phos 3.5 mg/dL
Uric Acid 3.5
T4 7.3 mcg/dL
TSH 1.04 mIU/L
A1C
7.5%
Color; appearance clear; SG 1.010; pH 6.5; glucose (); bilirubin (); ketones (); blood
(); urobilinogen 0.2 mg/dL; nitrite (); leukocyte esterases (); epithelial cells
occasional per hpf; WBC occasional per hpf; RBCnone seen; bacteriatrace;
amorphousnone seen; crystals1+ calcium oxalate; mucusnone seen. Culture not
indicated.
GU Consult
Patient treated for UTI 2 weeks ago with Cipro 250 mg Q 12 h 3 days. Urine clear;
negative for glucose. Bladder examination with ultrasound revealed postvoid residual
estimate of 200 mL. Prostate approximately 50 g, enlarged, benign.
Problem list
1. BPH with urge incontinence
2. Erectile dysfunction
Questions
1. Drug Therapy Problems
Amitriptyline Anticholinergic effect

2. subjective data objective data Benign Prostatic Hyperplasia

Subjective Data
CC : Conrad McLaren is a 62-year-old I cant sleep at night. Im up four or five times
feeling that I have to urinate, and then when I get to the bathroom all I do is dribble.
Sometimes I dont even make it to the bathroom in time. I have a girlfriend now and I
regularly take Cialis. Going to the bathroom all night is really impacting my love life.
HPI : hospitalized twice in the past 3 years for urosepsis. History of worsening urinary
hesitancy, nocturia, and dribbling
PMH : HTN,BPH with urge incontinence,Chronic UTIs,Type2DM,ED
Drug allergy : NKDA
Objective Data
Med : Amitriptyline 50 mg PO at bedtime
PE : V/S : BP 140/95, P72, RR 18, T 37 C, Wt 115.2 kg ,Ht 180 cm
Genit/Rect: DRE; prostate enlargement with symmetry and rubbery, penis circumcised
w/o DC MS/Ext: Neurovascular intact; distal pulses 12+
Labs: BUN 9 mg/dL
SCr 0.7 mg/dL
UA : Glucose (-),Blood (-),Nitrite (-), RBC not seen
GU Consult
Patient treated for UTI 2 weeks ago with Cipro 250 mg Q 12 h 3 days. Urine clear;
negative for glucose. Bladder examination with ultrasound revealed postvoid residual
estimate of 200 mL. Prostate approximately 50 g, enlarged, benign.
3. Benign Prostatic Hyperplasia

 Stromal Epithelial hyperplasia Stromal cell a-1 adrenergic

receptor

4.
: ,
5. Benign Prostatic Hyperplasia

6. (list the drug, dosage form, dose,

schedule, duration of therapy)
irritative voiding symptom Complication UTI
2
moderate
symptom

Monotherapy 5d-reductase inhibitor >

40 g
Finasteride 5 mg PD OD, Peak onset 3-6 mo
7.

Bladder
8. Efficacy monitoring parameter ADR monitoring parameter
Efficacy monitoring baseline 6 Prostate size , Peak
urinary flow rate Voiding symptom
ADR monitoring : Ejaculation disorder

 (Urinary incontinence)
A74-year-old man develops urinary urgency and frequency 6 weeks after
experiencing stroke. He has a history of essential hypertension and is taking
hydrochlorothiazide and terazosin. Diagnostic tests indicate the presence of urge
incontinence caused by the stroke and possibly aggravated by his drug therapy.
Several non pharmacologic therapies may be instituted to reduce incontinent
episodes.
Questions
1. Drug Therapy Problems
Urge incontinence
2. (signs, symptoms, medical history, laboratory values, other test results)

(Urge Incontinence)
Sign & symptom

- > 8 /
-

- > 1 ,
Medical history
- neurologic disease : stroke,Parkinsoms disease,multiple sclerosis,spinal cord
injury
- Bladder outlet sbstruction : BPH
- Diuretics,acetylcholinesterase inhibitors,alpha adrenergic antagonist
Labs: - Urodynamics (
)

- (Urinary analysis )

- : ,,

- Postvoid residual volume (PVR) :

(Dx Overflow incontinence PVR >400 mL)

Urge incontinence Stroke
hydrochlrothiazide terazosin
3. (differentiate) Urge incontinence Stress incontinence, Over flow
incontinence,Functional incontinence

4. urge
incontinence

a-receptor antagonist,CCBs,Narcotic
analgesic,Anticholinergic,Antidepressant,alcohol
5.

6. (non-pharmacologic alternatives)

caffeine

pessary

- (Bladder training) 1 hr

15-30 min/wk 2-3 hr (urge incontinence

57% )

7. (pharmacologic therapy)
(urge incontinence) regimen (list the drug, dosage form, dose,
schedule, and duration oftherapy)
Anticholinergic/antispasmodic
- Oxybutynin
IR 5 mg bid-tid
XL 5-30 mg OD
TDS 3-9mg/day 1 q 2 wk
- Tolterodine
IR 1-2 mg bid

LA 2-4 mg OD
- Trospium chloride 20 mg OD BID
- Solifenacin
5-10 mg OD
- Daifenacin
7.5-15 OD
TCA Imipramine,Doxepin,Nortriptyline Desipramine 25-100 mg hs
Topical estrogen : Conjugated estrogen vaginal cream (0.5 g) 3 times per week
mo

8. Efficacy monitoring parameter ADR monitoring parameter

Efficacy monitoring : Voiding symptom
ADR monitoring : Dry mouth,Constipation,somnolence,Nausea

9.
,

Self-study assignments
toilet behavior

10. (pharmacologic therapy)

(female stress urinary incontinence)

- Duloxetine 40-80 mg/day

- a-adrenergic agonist
>>> Pseudoephidrine 15-60 mg TID
>>> Phenylephrine 10 mg QID
- Estrogen
- Imipromine 20-100 mg HS
-