Prostate Cancer with Failure to Thrive

S – Situation

Patient is a77-year-old male with past medical history of metastatic prostate cancer (on androgen deprivation therapy, bone mets), HFrEF due to NICM, CKD IIIb, DM on insulin, HTN, HLD, nephrolithiasis with prior urosepsis, and long-standing urinary incontinence. He presents with failure to thrive and ongoing bowel and urinary incontinence. Recently with home insecurity x1 month, staying intermittently in respite/friend’s truck, with recent multiple ED visits (7 in past 30 days, most recent discharge last week). Today he reported left abdominal pain that resolved after large episode of bowel incontinence. Denies fever, chills, dysuria, acute back pain, weakness, or saddle anesthesia.

B – Background

• Extensive PMHx: prostate cancer metastatic to bone (scapula, 12th rib), CHF, DM (on Lantus 24 units nightly), HTN, HLD, CKD IIIb, nephrolithiasis, prior bacteremia with endocarditis, cellulitis, sepsis.

• Surgical history: left ureteral stent, glaucoma surgery, tonsillectomy/adenoidectomy, colonoscopy.

• Allergies: Keflex → rash (tolerated cefazolin, ampicillin).

• Medications: ASA, statin, Coreg, Jardiance, losartan, spironolactone, torsemide, insulin (switching to Tresiba + ISS), Flomax, enzalutamide, multivitamin, sertraline, DVT prophylaxis with heparin SQ in-house.

• Social: homeless, currently without stable housing; willing to contact sister for possible placement. Quit smoking 48 years ago (10 pack-year history), uses cannabis, no EtOH.

• Family hx: Alzheimer’s (mother), cancer (father), depression (maternal grandmother, paternal grandfather).

• ROS: Positive for abdominal pain/distension, bowel and urinary incontinence. Otherwise negative.

A – Assessment

• Patient alert, oriented, obese, not in acute distress. Afebrile, vitals stable.

• Abdomen: distension, mild tenderness, no guarding or hernia.

• Neuro: no focal deficits, intact LL power/sensation, no saddle anesthesia.

• GU: longstanding urinary incontinence.

• UA: leukocyte positive, nitrite negative.

• Imaging from last week reviewed, no acute findings.

• Labs pending.

• No evidence for acute cauda equina, cord compression, or acute infection at present.

• Main issues:

  • Failure to thrive with bowel/urinary incontinence.

  • Housing instability with recurrent ED visits.

  • Metastatic prostate cancer with chronic comorbidities.

R – Recommendation / Plan

1. Bowel and Urinary Incontinence

   • Monitor closely; no acute neuro deficits.

   • UA with leukocytes, culture pending; hold antibiotics unless symptomatic or positive culture.

   • Continue Flomax.

   • Monitor for UTI; reconsider SGLT-2 inhibitor if recurrent UTIs occur.

2. Failure to Thrive / Housing Instability

   • Admit for disposition planning.

   • Social work consult: evaluate placement options, possible stay with sister vs facility.

3. Prostate Cancer with Bone Mets / Chronic Illnesses

   • Continue home oncologic and cardiac meds (ASA, statin, Coreg, Jardiance, aldactone, torsemide, losartan).

   • Insulin: switch to Tresiba + ISS while inpatient.

   • Continue sertraline.

   • SQ heparin for DVT prophylaxis.

4. Monitoring

   • Daily labs (BMP, CBC).

   • Monitor for neuro changes (saddle anesthesia, weakness).

   • Symptom management as needed.