I-HUMAN CASE STUDY WEEK #10
“IM PEING ALL THE TIME” – THOROUGH ANALYSIS OF A 62-YEAR-OLD MALE
COMPLETE EXPERT REVIEW: DIAGNOSIS, MANAGEMENT, SOAP NOTES, AND
EVIDENCE-BASED CARE PLAN
2026 EDITION
1
,TABLE OF CONTENTS
CASE OVERVIEW AND PATIENT DEMOGRAPHICS ................................................ 1
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS (HPI) ............................. 2
PAST MEDICAL, SURGICAL, FAMILY, AND SOCIAL HISTORY ................................. 4
REVIEW OF SYSTEMS (ROS) ....................................................................... 6
PHYSICAL EXAMINATION FINDINGS ............................................................... 8
DIAGNOSTIC TESTS ORDERED AND RESULTS ................................................... 10
DIFFERENTIAL DIAGNOSIS WITH RATIONALE .................................................... 12
SOAP NOTES (DETAILED) ......................................................................... 14
FINAL DIAGNOSIS AND PATHOPHYSIOLOGY .................................................... 16
EVIDENCE-BASED MANAGEMENT PLAN ...................................................... 18
PATIENT EDUCATION, FOLLOW-UP, AND PREVENTION ...................................... 20
REFERENCES AND CLINICAL GUIDELINES ...................................................... 22
APPENDIX: KEY TEACHING POINTS AND RED FLAGS ..................................... 24
2
, SECTION 1: CASE OVERVIEW AND PATIENT DEMOGRAPHICS
PATIENT NAME: JAMES THOMPSON
AGE: 62 YEARS
GENDER: MALE
HEIGHT: 6'1" (185 CM)
WEIGHT: 212 LBS (96.2 KG)
BMI: 28.0 (OVERWEIGHT)
RACE/ETHNICITY: CAUCASIAN
OCCUPATION: RETIRED ACCOUNTANT (STILL DOES PART-TIME CONSULTING)
REASON FOR ENCOUNTER (CHIEF COMPLAINT):
“I’M PEING ALL THE TIME – DAY AND NIGHT. IT’S DRIVING ME CRAZY.”
CASE SETTING: Outpatient primary care clinic (self-referred, no prior urologic workup).
This Week #10 i-Human case focuses on lower urinary tract symptoms (LUTS) in an older
male, emphasizing differentiation of benign prostatic hyperplasia (BPH) from other causes
such as diabetes mellitus, prostate cancer, urinary tract infection (UTI), overactive bladder,
and prostatitis. [web:1][web:4][web:22]
Key learning objectives include:
- Performing a focused genitourinary (GU) history and physical.
- Performing and interpreting digital rectal exam (DRE), IPSS, and post-void residual (PVR).
- Ordering appropriate labs and studies (UA, PSA, BMP, glucose/HbA1c).
- Initiating guideline-aligned, evidence-based pharmacologic and non-pharmacologic
management of BPH-related LUTS. [web:14][web:17][web:22]
3
“IM PEING ALL THE TIME” – THOROUGH ANALYSIS OF A 62-YEAR-OLD MALE
COMPLETE EXPERT REVIEW: DIAGNOSIS, MANAGEMENT, SOAP NOTES, AND
EVIDENCE-BASED CARE PLAN
2026 EDITION
1
,TABLE OF CONTENTS
CASE OVERVIEW AND PATIENT DEMOGRAPHICS ................................................ 1
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS (HPI) ............................. 2
PAST MEDICAL, SURGICAL, FAMILY, AND SOCIAL HISTORY ................................. 4
REVIEW OF SYSTEMS (ROS) ....................................................................... 6
PHYSICAL EXAMINATION FINDINGS ............................................................... 8
DIAGNOSTIC TESTS ORDERED AND RESULTS ................................................... 10
DIFFERENTIAL DIAGNOSIS WITH RATIONALE .................................................... 12
SOAP NOTES (DETAILED) ......................................................................... 14
FINAL DIAGNOSIS AND PATHOPHYSIOLOGY .................................................... 16
EVIDENCE-BASED MANAGEMENT PLAN ...................................................... 18
PATIENT EDUCATION, FOLLOW-UP, AND PREVENTION ...................................... 20
REFERENCES AND CLINICAL GUIDELINES ...................................................... 22
APPENDIX: KEY TEACHING POINTS AND RED FLAGS ..................................... 24
2
, SECTION 1: CASE OVERVIEW AND PATIENT DEMOGRAPHICS
PATIENT NAME: JAMES THOMPSON
AGE: 62 YEARS
GENDER: MALE
HEIGHT: 6'1" (185 CM)
WEIGHT: 212 LBS (96.2 KG)
BMI: 28.0 (OVERWEIGHT)
RACE/ETHNICITY: CAUCASIAN
OCCUPATION: RETIRED ACCOUNTANT (STILL DOES PART-TIME CONSULTING)
REASON FOR ENCOUNTER (CHIEF COMPLAINT):
“I’M PEING ALL THE TIME – DAY AND NIGHT. IT’S DRIVING ME CRAZY.”
CASE SETTING: Outpatient primary care clinic (self-referred, no prior urologic workup).
This Week #10 i-Human case focuses on lower urinary tract symptoms (LUTS) in an older
male, emphasizing differentiation of benign prostatic hyperplasia (BPH) from other causes
such as diabetes mellitus, prostate cancer, urinary tract infection (UTI), overactive bladder,
and prostatitis. [web:1][web:4][web:22]
Key learning objectives include:
- Performing a focused genitourinary (GU) history and physical.
- Performing and interpreting digital rectal exam (DRE), IPSS, and post-void residual (PVR).
- Ordering appropriate labs and studies (UA, PSA, BMP, glucose/HbA1c).
- Initiating guideline-aligned, evidence-based pharmacologic and non-pharmacologic
management of BPH-related LUTS. [web:14][web:17][web:22]
3
