Teaching advanced bedside evaluation of the man whose urination has changed.

I have a medical student rotating with me from MSU this month.  The clinic provides a good environment for teaching due to the prevalence of persons with no medical care in the recent past, who at times have very advanced disease.  Unfortunately for many students, they never actually see a patient who has not already been poked, prodded, imaged, irradiated and chemically profiled 100 times prior to their encounter with the patient.

Monday would provide a contrast of two persons who present with superficially similar symptoms, but have drastically different diagnosis and prognosis.

Luis is a 50 year old Cuban man with mild prostatic symptoms.  He's fit, well groomed, humorous, and well muscled from physical work.  He has not gained the American belly fat due to having immigrated recently.   On exam he appears younger than his stated age.  His prostate is mildly enlarged without a hind of nodularity or tumor.  His PSA is normal.  He has responded well to a medication designed to ease the mild slowing of urination caused by the pressure of his expanding prostate.  He is reassured that his condition is mild, though progressive, and may need surgery in 5 -10 years.

Leister is a 55 year old Black man who has not seen a doctor in decades.  As I enter the room he appears gaunt, wasted, and strangely unresponsive to my greeting...managing only a faint mumbling while looking into the distance.   He complains of pain in his left flank, has no appetite, and has lost weight.  He is urinating less, though it's not clear if that's do to his lack of eating and drinking.  Pounding over his kidneys demonstrates tenderness over the left kidney only.  The abdomen is thin and flat.  There's no fat layer in his skin and his skin and hair are dull.  The muscles are wasting away in his temples and face.  His teeth are missing and the gums have turned white, suggesting a precancerous change.  On rectal exam there is a large bulging prostate which is not hard or nodular.
Later that day a phone call from radiology confirms my suspicion:  a calcified tumor in his bladder blocking the left urinary tube and causing back pressure to the left kidney.  Advanced cancer until proven otherwise.