Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of elevated PSA level (current PSA: [Value] ng/mL). Patient denies obstructive voiding symptoms, hematuria, or bone pain. Family history significant for [Positive/Negative] prostate cancer. Digital Rectal Exam (DRE) reveals [Symmetric/Asymmetric] prostate, [Soft/Indurated] consistency, [Presence/Absence] of nodules, and [Preserved/Obliterated] median sulcus.
Clinical Examination Findings
General: Patient is alert and oriented, in no acute distress. Abdomen: Soft, non-tender, non-distended, no palpable masses. Genitourinary: External genitalia normal. DRE: Prostate gland size estimated at [Size] grams, consistency [Firm/Hard/Nodular], mobility [Fixed/Mobile], rectal mucosa smooth, no blood on glove. Lymph nodes: No palpable inguinal lymphadenopathy.
Treatment Protocol
Plan: 1. Prostate MRI (PI-RADS scoring) to assess local extent. 2. Transrectal Ultrasound (TRUS)-guided biopsy or MRI-fusion biopsy to confirm histology and Gleason score. 3. Staging workup including bone scan and CT abdomen/pelvis if indicated by high-risk features. 4. Discuss therapeutic options: Radical Prostatectomy, External Beam Radiation Therapy (EBRT), or Active Surveillance based on risk stratification.