Differential diagnosis and mini cases : Nausea/vomiting, abdominal pain, constipation/diarrhea, upper GI bleeding, blood in stool, hematuria, other urinary problems

Question 1

Nausea and vomiting - key history ?

Answer 1

1. Acuity of onset;
2. ± Abdominal pain;
3. Relation to meals;
4. Sick contacts;
5. Possible food poisoning;
6. Possible pregnancy;
7. Neurologic symptoms (headache, stiff neck, vertigo, focal numbness or weakness);
8. Urinary symptoms; other associated symptoms (GI, chest pain);
9. Exacerbating and alleviating factors;
10. Medications;
11. History of prior abdominal surgery;

Question 2

What are important ascpects to remeber when taking history from a patient who complains of vomiting ?

Answer 2

• Make sure it is vomiting and not regurgitaion, or reflux;
• Identify associated symptoms - abdominal pain, fever, GI bleeding;
• Identify complications - dehydration, acidosis, weight loss etc.;
• Remember about pregnancy in a female in reproductive capacity => do a urine or serum human chorionic gonadotropin pregnancy test;

Question 3

What should be your differential diagnosis of nausea and vomiting ?

Answer 3

1. Gastroenteritis;
2. Food poisoning;
3. Other GI : gastroc outlet or intestinal obstruction, cholecystitis, appendicitis, pancreatitis, peptic ulcer, liver disease, pancreatitis;
4. CV : AMI, mesenteric ischemia;
5. Respiratory : Legionnaire’s disease
6. GU/reproductive : pyelonephritis, kidney failure, pregnancy;
7. Endocrine : adrenal insufficiency, pituitary infarcion, meningitis, autonimic neuropathy;
8. Opthalmic : angle-closure glaucoma;
9. Vestibular : motion-sickness, vestibular neuritis;
10. CNS : increased intracranial pressure due to tumor, pseudotumor cerebri, cerebral edema, or encephalopathy;
11. Psychiatric : anxiety, eating disorders;
12. Multisystem, metabolic : toxins, medicines, acidosis, post-chemotherapy;

Question 4

What questions will you ask to a patient presenting with nausea/vomiting ?

Answer 4

1. Tell me more about your nausea and vomiting ? Please describe what you are experiencing.
2. When did the vomiting start ? When during the day do you vomit ?
3. Tell me about the first time it happened.
4. How often are you throwing up ?
5. Have you ever experienced something like this before ?
6. Are you throwing up any blood ? Are you passing any blood in your stools ?
7. Is the vomitus bloddy ? Does it contain bile ? Does it contain partially digested food ? Is it feculent ?
8. Do you have any : abdominal pain / constipations / diarrhea / headache / fever / chills / burning with urination ?
9. Does the room feel like spinning ?
10. Have you lost weight recently ?
11. Have you had problems like this before ?
12. Did you eat in a restaurant ? Did you eat any leftover food ? Is anyone else who ate the same thing sick ?
13. When was your last period ? Is there a chance you may be pregnant ?
14. What do you think is the cause of your nausea and vomiting? Have you been able to establish a pattern?
15. Think about your most recent episode of nausea and vomiting. What did you do that day, starting from when you woke up in the morning?
16. Have you been diagnosed with any other medical conditions ?
17. Have you had any surgeries / traumas / injuries ?
18. Do you take any medications ?
19. Do you smoke ? At what age did you start and how much do you smoke ?
20. Do you drink alcohol ? How much ? How often ?
21. Have you used recreational drugs ?
22. Do you have :
    
    1. Diarrhea, headache, myalgia, or fever? => Viral gastroenteritis;
    2. Headache, neck stiffness, altered mentation, or photophobia? => Meningitis
    3. Low weight or weight loss? => Eating disorder; Gastrointestinal malignancy
    4. Lack of concern regarding weight loss or vomiting? => Eating disorder
    5. Jaundice, dark urine, or light stools? => Hepatitis; Choledocholithiasis;
    6. Chest pain or cold sweats (diaphoresis) ? => Myocardial infarction
    7. Crampy, colicky abdominal pain? => Bowel obstruction
    8. Upper abdominal pain (biliary colic) => Cholecystitis or cholelithiasis
    9. Epigastric abdominal pain radiating to the back? => Pancreatitis
    10. Abdominal pain that worsens with jolting movements? => Bowel perforation, Peritonitis
    11. Migraine headaches? => Cyclic vomiting syndrome
    12. Vertigo? => Labyrinthitis

Question 5

What physical exam will you perform to a patient with CC : nausea and vomiting ?

Answer 5

1. General - assess level of alertness;
2. Vital signs - chyck for orthostatic hypotension if not already given in vital signs;
3. HEENT - examine oropharynx for dry mucus membranes, examine fundi if uspecting increased intracranial pressure;
4. Heart - aucultate for murmurs, gallops, rubs;
5. Abdomen : inspect for distention, auscultate for bowel sounds, percuss for bowel gas pattern, palpate for tenderness, examine for CVA tenderness;

Question 6

What tests will you consider ordering in a “nausea and vomiting” encounter ?

Answer 6

1. Urine pregnancy test - urine hCG
2. Rectal exam, Pelvic exam
3. CBC with differential
4. Serum electrolytes - sodium, potassium, chloride, calcium
5. Glucose
6. Creatinine and BUN
7. Liver function panel
8. Lipase, amylase
9. Abdominal/biliary/pelvic US
10. Urinalysis and culture
11. Abdominal XR - flat and upright if you suspect obstruction
12. HIV antibody

Question 7

What is your differential diagnosis and workup plan ?

“20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they occasionally use condoms for contraception” ?

Answer 7

• Differential diagnosis :
  
  1. Pregnancy
  2. Gastritis
  3. Hypercalcemia
  4. Diabetes mellitus
  5. UTI
  6. Depression
• Workup plan :
  
  • Urine hCG
  • Pelvic exam
  • U/S—pelvis
  • CBC
  • Electrolytes, calcium, glucose
  • UA, urine culture
  • HIV antibody

Question 8

Abdominal pain - key history ?

Answer 8

1. Location, quality, intensity, duration, radiation, timing (relation to meals);
2. Sssociated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic);
3. Exacerbating and alleviating factors;
4. History of similar symptoms;
5. History of abdominal surgeries, trauma, gallstones, renal stones, atherosclerotic vascular disease;
6. Medications (eg, NSAIDs, corticosteroids);
7. Alcohol and drug use;
8. Domestic violence, stress/anxiety, sexual history, pregnancy history.

Question 9

Abdominal pain - key physical examination ?

Answer 9

1. Vital signs;
2. Heart and lung exams;
3. Abdominal exam, including tenderness, guarding, rebound, Murphy’s sign, psoas and obturator signs, and CVA percussion;
4. Bowel sounds, aortic bruits;
5. Rectal exam;
6. Pelvic exam (women).

Question 10

What general/introductory questions will you ask to evaluate the cause of abdominal pain ?

Answer 10

1. I’m sorry to hear that you’re having belly pain. Can you tell me more about it? => allow the patient to tell you about his pain, do not interrupt;
2. When did your abdominal pain begin?
3. I can tell that this abdominal pain is very uncomfortable for you; I’d like to ask you some questions so I can understand what is causing your pain => Reassurance will put the patient at ease and facilitate the interview.
4. What makes the pain worse or better ?
5. What is the character of the pain ?
6. Does this pain move anywhere ?
7. Could you please try to rate your pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the strongest pain you’ve ever felt.
8. How long have you had this pain for ?
9. Has this pain been intermittent or constant - does it go on and off or is it there all the time ?
10. Have you tried anything to treat your pain ? HAs anything helped ?

Question 11

What are some serious diagnoses of abdominal pain that you should have at the back of your head ?

Answer 11

1. Abdominal aortic aneurysm
2. Adnexal torsion
3. Acute adrenal insufficiency
4. Aortic dissection - thoracic
5. Appendicitis
6. Cholangitis
7. Cholecystitis
8. Bowel obstruction
9. Celiac sprue
10. Diabetic ketoacidosis
11. Diverticulitis
12. Endometriosis
13. Familial Mediterranean fever
14. Hernia - incarcerated
15. Hypercalcemia
16. Inflammatory bowel disease - CD, UC
17. Acute intestinal ischemia
18. Chronic intestinal ischemia
19. Irritible bowel syndrome
20. Malignancy - occult
21. Myocardial infarction or ischemia
22. Nephrolithiasis
23. Pancreatitis - acute or chronic
24. Pelvic inflammatory disease
25. PUD
26. Porphyria
27. Ectopic pregnancy
28. Pulmonary infarct
29. Sickle cell crisis
30. Testicular torsion
31. Vasculitis

Question 12

What focused questions should you ask a patient with abdominal pain ? What does “PQRST” stand for ?

Answer 12

1. Provoke => Does eating worsen the pain ? Does eating alleviate the pain ?
2. Quality => Is the pain associated with nausea or vomiting ? Is the pain tearing ? Is the pain crampy ? Is the pain associated with regurgitation of undigested food ?
3. Radiation => Does the pain move anywhere ?
   
   • ​to the back ? => pancreatitis, duodenal ulcer, gastric ulcer, aortic dissection;
   • right shoulder ? => cholecystitis, biliary colic;
   • left shoulder ? => splenic infarction, splenomegaly;
   • left arm or left neck ? => myocardial ischemia;
4. Severity ? => Did the pain suddenly became more tolerable ? Did the pain hurt the most at its onset?
5. Timing and treatment ? => Is the pain continuous with intermittent waves of worsening pain? Are there multiple waves of pain that increase in intensity, then stop abruptly for short periods of time? Did you recently take antibiotics? Does the pain occur once monthly around 2 weeks after the beginning of your menses, occasionally associated with vaginal spotting?

Question 13

What is your differential diagnosis and workup plan ?

“45 yo M presents with sudden onset of colicky right- sided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness”

Answer 13

• Differential diagnosis ?
  
  1. Nephrolithiasis
  2. Renal cell carcinoma
  3. Pyelonephritis
  4. Cholecytsitis
  5. GI etiology : appendicitis
• Workup plan :
  
  • Abdominal US - renal
  • Abdominal CT
  • KUB
  • CBC, CRP, ESR
  • Electrolytes
  • Creatinine, BUN
  • Urine examination, culture, cytology
  • Blood culture
  • IVP

Question 14

What is your differential diagnosis and workup plan ?

“60 yo M presents with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam”

Answer 14

• Differential diagnosis :
  
  • Pancreatic cancer
  • Cholangiocarcinoma
  • Acute viral hepatitis
  • Acute alcoholic hepatitis
  • Chronic pancreatitis
  • Cholangitis
  • PUD
  • Aortic dissection
• Workup plan :
  
  • Abdominal CT, abdominal US
  • Lipase, amylase
  • Liver function tests : AST, ALT, bilirubin, alkaline posphatase
  • CBC, CRP, ESR
  • Electrolytes

Question 15

What is your differential diagnosis and workup plan ?

“56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea, vomiting. He is an alcoholic and has spent the past 3 days binge drinking”

Answer 15

• Differential diagnosis :
  
  1. Acute pancreatitis
  2. Chronic pancreatitis
  3. PUD
  4. Esophagitis
  5. Cholecystitis/choledocholithiasis
  6. Gastritis
  7. Abdominal aortic aneurysm
  8. Mesenteric ischemia
  9. Alcoholic hepatitis
  10. Boerhaave syndrome
• Workup plan :
  
  • CBC, Electrolytes, BUN/Cr
  • Amylase, lipase
  • AST/ALT/bilirubin/alkaline phosphatase
  • U/S—abdomen, CT—abdomen
  • Upper endoscopy
  • ECG

Question 16

What is your differential diagnosis and workup plan ?

“41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy’s sign”

Answer 16

• Differential diagnosis :
  
  • Acute cholecytitis
  • Choledocholithiasis
  • Ascending cholangitis
  • Acute hepatitis
  • Peptic ulcer disease
  • Fitz-Hugh–Curtis syndrome
  • Acute subhepatic appendicitis
• Workup plan :
  
  • CBC
  • AST/ALT/bilirubin/alkaline phosphatase
  • U/S—abdomen
  • CT—abdomen
  • Blood culture

Question 17

What is your differential diagnosis and workup plan ?

“43 yo obese F presents with RUQ abdominal pain, fever, jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam”

Answer 17

• Differential diagnosis :
  
  • Ascending cholangitis
  • Acute gallstone cholangitis
  • Acute cholecystitis
  • Hepatitis
  • Sclerosing cholangitis
  • Fitz-Hugh–Curtis syndrome
• Workup plan :
  
  • CBC
  • AST/ALT/bilirubin/alkaline phosphatase
  • Blood culture
  • Viral hepatitis serologies
  • U/S—abdomen
  • MRCP
  • ERCP

Question 18

What is your differential diagnosis and workup plan ?

“25 yo M presents with RUQ pain, fever, anorexia, nausea, vomiting. He has dark urine and clay-colored stool”

Answer 18

• Differential diagnosis :
  
  • Acute hepatitis
  • Acute cholecystitis
  • Ascending cholangitis
  • Choledocholithiasis
  • Pancreatitis
  • Acute glomerulonephritis
  • Biliary tract obstruction
  • Ascending cholangitis
  • Wilson’s disease
• Workup plan :
  
  • CBC
  • Amylase, lipase
  • AST/ALT/bilirubin/alkaline phosphatase
  • Viral hepatitis serologies
  • UA
  • U/S—abdomen

Question 19

What is your differential diagnosis and workup plan ?

“35 yo M presents with burning epigastric pain that starts 2–3 hours after meals. The pain is relieved by food and antacids”

Answer 19

• Differential diagnosis :
  
  • Peptic ulcer disease - gastric or duodenal
  • Gastritis
  • GERD
  • Esophagitis
  • Cholecystitis
  • Chornic pancreatitis
  • Atypical angina
  • Mesenteric ischemia
• Workup plan :
  
  • Rectal exam, stool for occult blood
  • Amylase, lipase, lactate
  • AST/ALT/bilirubin/alkaline phosphatase
  • Upper endoscopy (including H pylori
    testing)
  • Upper GI series

Question 20

What is your differential diagnosis and workup plan ?

“37 yo M presents with severe epigastric pain, nausea, vomiting, mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a daily basis”

Answer 20

• Differential diagnosis :
  
  • Perforated peptic ulcer
  • Acute pancreatitis
  • Hepatitis
  • Cholecystitis
  • Gallstone cholangitis
  • Acute mesenteric ischemia
• Workup plan :
  
  • Rectal exam
  • CBC, Electrolytes
  • Amylase, lipase, lactate
  • AST/ALT/bilirubin/alkaline phosphatase
  • CXR, KUB
  • CT—abdomen
  • Upper endoscopy (including H pylori testing)
  • Blood culture

Question 21

What is your differential diagnosis and workup plan ?

“18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago”

Answer 21

• Differential diagnosis :
  
  • Splenic rapture
  • Splenic infarction
  • Rib fracture
  • Pneumonia
  • Perforated peptic ulcer
• Workup plan :
  
  • CBC, Electrolytes
  • CXR
  • CT—abdomen, U/S—abdomen (if hemodynamically unstable)

Question 22

What is your differential diagnosis and workup plan ?

“40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries

Answer 22

• Differential diagnosis :
  
  • Intestinal obstruction
  • Small bowel or colon cancer
  • Volvulus
  • Gastroenteritis
  • Food poisoning
  • Ileus
  • Hernia
• Workup plan :
  
  • Rectal exam
  • CBC, Electrolytes
  • AXR CT—abdomen/pelvis with contrast
  • Colonoscopy

Question 23

What is your differential diagnosis and workup plan ?

“70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam”

Answer 23

• Differential diagnosis :
  
  • Mesenteric ischemia/infarction
  • Diverticulitis
  • Peptic ulcer disease
  • Gastroenteritis
  • Acute pancreatitis
  • Cholecystitis
• Workup plan :
  
  • Rectal exam
  • CBC
  • Amylase, lipase, lactate
  • ECG
  • AXR
  • CT—abdomen
  • Mesenteric angiography
  • Barium enema

Question 24

What is your differential diagnosis and workup plan ?

“21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs. She has been told that she had a cyst on her right ovary”

Answer 24

• Differential diagnosis :
  
  1. Ovarian torsion
  2. Appendicitis
  3. Nephrolithiasis
  4. Ectopic pregnancy
  5. Ruptured ovarian cyst
  6. Pelvic inflammatory disease
  7. Bowel infarction or perforation
• Workup plan :
  
  • Pelvic exam
  • Urine hCG
  • Doppler U/S—pelvis
  • Rectal exam
  • UA, CBC
  • CT—abdomen
  • Laparoscopy
  • Chlamydia and gonorrhea testing, VDRL/RPR

Question 25

What is your differential diagnosis and workup plan ? "68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet"

Answer 25

* Differential diagnosis : * Diverticulitis * Crohn’s disease * Ulcerative colitis * Gastroenteritis * Abscess * Workup plan : * Rectal exam * CBC * Electrolytes * CXR, AXR, CT—abdomen * Blood culture

Question 26

What is your differential diagnosis and workup plan ? "20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive"

Answer 26

* Differential diagnosis : * Acute appendicitis * Gastroenteritis * Diverticulitis * Crohn’s disease * Nephrolithiasis * Volvulus or other intestinal obstruction * Perforation * Acute cholecystitis * Workup plan : * CBC * Electrolytes * CT—abdomen * AXR * U/S—abdomen * Blood culture

Question 27

What is your differential diagnosis and workup plan ? "30 yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia"

Answer 27

* Differential diagnosis : * Irritable bowel syndrome * Crohn’s disease * Celiac disease * Chronic pancreatitis * GI parasitic infection (amebiasis, giardiasis) * Endometriosis * Workup plan : * Rectal exam, stool for occult blood * Pelvic exam * Urine hCG * CBC * Electrolytes * Colonoscopy CT—abdomen/pelvis * Stool for ova and parasitology, Entamoeba histolytica antigen

Question 28

What is your differential diagnosis and workup plan? "24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual pe- riod. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had un- protected sex with multiple sexual partners"

Answer 28

* Differential diagnosis : * Pelvic inflammatory disease * Endometriosis * Dysmenorrhea * Vaginitis, Cystitis * Spontaneous abortion * Pyelonephritis * Workup plan : * Pelvic exam * Urine hCG * Cervical cultures * CBC, ESR * UA, urine culture * U/S—pelvis

Question 29

Constipation/Diarrhea - key history ?

Answer 29

1. Frequency, color, odor, volume of stools; 2. Presence of **mucus, blood**, flatulence; 3. Whether stools **float** in bowl; 4. **Duration** of change in bowel habits; 5. **Associated** symptoms (constitutional, abdominal pain, bloating, **tenesmus**, **sense of incomplete evacuation**, melena, hematochezia); 1. **_Melena_** is the passage of black, tarry stools; 2. **_Hematochezia_** is the passage of fresh blood per anus, usually in or with stools; 6. **Thyroid** disease symptoms (eg, feeling hot, palpitations, weight loss); 7. **Diet** (especially fiber and fluid intake); 8. **Medications** (including recent antibiotics); 9. **Sick** contacts, **travel**, camping, **HIV** risk factors; 10. History of abdominal **surgeries**, diabetes, **pancreatitis**; 11. **Alcohol** and drug use; 12. Family history of **colon cancer.**

Question 30

Constipation/diarrhea - key physical exam ?

Answer 30

1. Vital signs; 2. Relevant **thyroid**/endocrine exam; 3. Abdominal and rectal exams; 4. ± female pelvic exam.

Question 31

What will be your differential diagnosis of constipation in a patient ?

Answer 31

1. Anorectal obstruction : Anal fissure, Colon or rectal cancer, Colonic polyps, Fecal impaction, Ileus, Megarectum, Strictures, Thrombosed hemorrhoids, Defecatory disorders, Pregnancy; 2. Metabolic and endocrine conditions : Diabetes mellitus, Hypercalcemia, Hyperparathyroidism, Hypokalemia, Hypomagnesemia, Hypothyroidism, Lead poisoning, Pregnancy, Uremia; 3. Neurogenic disorders : Autonomic neuropathy, Chagas disease, Hirschsprung disease, Neurofibromatosis, Central nervous system disorders, Multiple sclerosis, Parkinsonism, Spinal cord tumor or injury, Cerebrovascular accident, Muscular and connective tissue disorders, Amyloidosis, Systemic sclerosis, Myotonic dystrophy 4. Medication side effect : Antacids (aluminum- and calcium-containing), Anticholinergics, Antidiarrheals, Antidepressants, Antipsychotics, Antispasmodics, Calcium supplements, Cholestyramine, Clonidine, Iron supplements, Levodopa, NSAIDs, Opiate analgesics, Sympathomimetics, Verapamil 5. Colorectal motility dysfunction: Slow transit constipation, Constipation-predominant IBS, Defecatory disorders, Idiopathic chronic constipation 6. Psychosocial : Depression, Low-fiber diet, Sedentary lifestyle, Somatization

Question 32

What are 10 important aspects of an interview with a patient c/o constipation ?

Answer 32

1. Make sure that the patient **indeed has constipation** : "tell me more about your problem" "could you please describe what do you mean by constipation" "how many bowel movements do you have every week?" =\> here allow the patient to fully describe his or her constipation before asking any clinician-centered questions; 2. Is it chronic or acute ? If **chronic** assess patient's idea of a normal bowel movements; 3. Assess for **alarm** symptoms ! 4. Assess for symptoms of chronic **functional** constipation; 5. Assess for **secondary** causes of constipation like hypothyroidism, IBS; 6. Remember - you must have complete **medication** list ! Many drug's side effects include constipation. 7. Obtain **dietary** history and **fluid** intake details. 8. Use **Bristol** stool chart if possible. 9. Ask how the constipation **affects** the patient's life and ask what he/she thinks might be causing it. 10. Seek out **emotion** and address it.

Question 33

What are some alarm symptoms associated with constipation ? What serious diagnosis should you have in mind ?

Answer 33

* Alarm symptoms include : 1. Acute-onset constipation; 2. Associaed fever; 3. Associated abdominal pain; 4. Weight loss; 5. Rectal bleeding 6. Family history of inflammatory bowel disease or cancer; 7. Age over 50 yrs; * Serious diagnoses : colon cancer, stricture, inflammatory bowel disease, spinal cord tumors/trauma, bowel obstruction, ileus;

Question 34

Define constipation according to Rome IV criteria

Answer 34

1. At least **3 months**, which need _not be consecutive_, in the **preceding 6 months** of *_2 or more_* of the following: 1. _Straining_ during at least **25%** of defecations 2. _Lumpy or hard_ stools in at least **25%** of defecations 3. Sensation of _incomplete evacuation_ in at least **25%** of defecations 4. Sensation of anorectal _obstruction/blockage_ in at least **25%** of defecations 5. _Manual maneuvers_ to facilitate at least **25%** of defecations (eg, digital evacuation, support of the pelvic floor) and/or 6. Fewer than **3 defecations per week**

Question 35

What questions will you ask to a patient presenting with constipation ?

Answer 35

1. Tell me about your constipation. 2. What do you mean when you say you are constipated ? 3. What do you think may be causing your symptoms ? 4. How has this been for you ? 5. Are you able to pass gas ? 6. Have your stools gotten narrow, like a pencil, or flattened, like a ribbon ? 7. Do you have abdominal pain or cramps ? 8. Do you have nausea or vomiting ? 9. Are you having fecal incontinence ? 10. Have you recently started a new medicine ? 11. Tell me about your diet. Describe a typical daily menu. Do you think you drink enough ? How many glasses of liquids do you drink daily ? 12. Has level of your activity changed recently ? 13. What were your bowel habits before this episode ? 14. Have you had an abdominal surgery or radiation ? 15. Have you suffered a back injury ? 16. Do you have any new weakness in your legs ? Do you feel any numbess around you rectum or genital area ? 17. Do you have any difficulties in passing urine ? 18. How often do you have bowel movements ? 19. For you, what would normal bowel function be ? 20. What is the most distressing symptom for you ? 21. Do you have difficulty passing soft stools ? 22. Do you ever need to press around your vagina/rectum with your fingers in order to move your bowels? 23. Do you ever need to evacuate your bowels with your finger? 24. Do you have difficulty letting go or relaxing your muscles to have a bowel movement? 25. Do you sometimes have a sensation that you have not completely emptied your bowels ? 26. Do you have an abdominal pain or bloating associated with bowel movements ? 27. Does anything help to alleviate your symptoms ? Like increasing fiber intake or laxative use ? 28. I would like to ask you about your mood. How are you feeling recently =\> screen for depression ! 29. Screen for hypothyroidism =\> ABCD HV 30. Can you please describe your stool for me ? =\> shape, size, color, consistency, blood or mucus?

Question 36

What is your differential diagnosis and workup plan ? "28 yo M presents with constipation (hard stool) for the past 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food"

Answer 36

* Differential diagnosis : 1. Low-fiber diet 2. Depression 3. Substance abuse (eg,heroin) 4. Irritable bowel syndrome 5. Hypothyroidism * Workup plan : * Rectal exam * TSH * Electrolytes * Urine toxicology

Question 37

What is your differential diagnosis and workup plan ? "67 yo M presents with **alternating diarrhea and constipation**, decreased **stool caliber**, and **blood** in the stool for the past 8 months. He also reports unintentional **weight loss**. He is on a low-fiber diet and has a family history of colon cancer. His last colonoscopy was _12 years ago_"

Answer 37

* Differential diagnosis : * Colorectal cancer * Irritable bowel syndrome * Diverticulosis * GI parasitic infection (ascariasis, giardiasis) * Inflammatory bowel disease * Workup plan : * Rectal exam, stool for occult blood * CBC, Electrolytes * AST/ALT/bilirubin/alkaline phosphatase * Colonoscopy * Barium enema * CT—abdomen/pelvis

Question 38

What is your differential diagnosis and workup plan ? "30 yo F presents with alternating constipation and diarrhea accompanied by abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool"

Answer 38

* Differential diagnosis : * Irritable bowel syndrome * Inflammatory bowel disease * Celiac disease * Chronic pancreatitis * GI parasitic infection (ascariasis, giardiasis) * Lactose intolerance * Workup plan : * Rectal exam, stool for occult blood * CBC * Electrolytes * Colonoscopy * Stool for ova and parasitology * CT—abdomen/pelvis

Question 39

Give differential diagnosis of diarrhea.

Answer 39

1. Functional diarhhea 2. Infectious diarrhea 3. Inflammatory bowel disease 4. Malabsorption 5. Laxative use 6. Medication-related, caffeine, alcohol 7. Postoperative diarrhea 8. Malignancies 9. Collagenous colitis 10. Idiopathic 11. Hyperthyroidism 12. Ischemic colitis

Question 40

What questions should be asked a patient presenting with diarrhea ?

Answer 40

1. **Tell me more** about your symptoms; 2. Please explain **what do you mean** by saying diarrhea ? 3. How **many times** a day are you going ? 4. Is **volume** of your stool greter than usual ? Do you have a large or small volume ? 5. **For how long** have you been having this diarrhea ? (\<2 weeks =\> acute, 2-4 weeks =\> persistent; \>4 weeks =\> chronic); 6. What is the **pattern**? Is it **continous** or do you have **normal** bowel movements in between ? 7. Do you see **blood/mucus/pus**? 8. Is the diarrhea **greesy or oily**? Is the stool oily and difficult to flush ? 9. Have you has any belly **pain**? Cramping ? Is this pain relieved after you pass stool ? 10. Ask if the patient feels weak, fatigued, dizzy, thirsty? =\> assess patient's **hydration** status - also during the physical exam ! 11. Have you changed your **diet**? 12. Has yout **weight** changed ? 13. Have you eaten anything that could cause these symptoms ? Have you **eaten** in a restaurant ? Does anybody with whom you've eaten have similar symptoms ? 14. Have you **travelled, been camping** recently ? 15. Could you please try to **describe your stool** for me - its volume, consitency, is it watery ? 16. Did this begin **suddenly** or did it come on **gradually** over some time ? 17. Do you have feelings of **full** belly ? 18. Do you have more **gasses** than usually ? 19. Do you have **nausea or vomiting**? 20. Do you have any **other symptoms**? =\> joint pain, fever, chills, nausea, vomiting, burning on passing urine, red eyes ? 21. Is your diarrhea associated with any particular **foods - milk, sweeteners, bread**? 22. Do your symptoms **persist** even though you don't eat ? 23. Have you taken any **antibiotics** recently ? Have you started any medications recently ? 24. Have you had any **surgeries**?

Question 41

What aspects of physical examination will be important in diarrhea encounter ?

Answer 41

1. General apparence - assess skin for jaundice, or other color change, look for rash, signs of fever, chills, lymphadenopathy; 2. Head and neck - assess hydration by examination of oropharynx, look for any mouth ulcers, thrush, assess dentition; remeber to inspect the eyes - look for conjuctivitis, episcleritis; palpate the neck for lymphadenopathy and assess thyroid size; 3. Chest and heart - auscultate the chest and heart - look for tachycardia; 4. Abdomen : inspect for scars and distention; auscultate for bowel sounds, percuss for bowel gas pattern, palpate for tenderness;

Question 42

What is your differential diagnosis and workup plan for this patient : "33 yo M presents with watery diarrhea, vomiting, diffuse abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill"

Answer 42

* Differential diagnosis : 1. Viral gastroenteritis 2. Bacterial gastroenteritis 3. Food poisoning * Workup plan : * Rectal exam * Electrolytes, glucose * Stool exam and culture, stool leukocytes, occult blood * CBC with differential * CRP, ESR * Abdominal US

Question 43

What is your differential diagnosis and workup plan for this patient : "40 yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI"

Answer 43

* Differential diagnosis : * Pseudomembranous (Clostridium difficile) colitis * Post-antibiotic diarrhea * Gastroenteritis * Cryptosporidiosis * Food poisoning * Inflammatory bowel disease * Workup plan : * Stool for C difficile toxin * Rectal exam * Stool for occult blood * Stool leukocytes and culture * CBC * Electrolytes

Question 44

What is your differential diagnosis and workup plan for this patient : "25 yo M presents with watery diarrhea and abdomi- nal cramps. He was recently in Mexico"

Answer 44

* Differential diagnosis : * Traveler's diarrhea - E.coli * Giardiasis * Amebiasis * Food poisoning * Hepatitis A * Cryptosporidiosis * Cholera * Workup plan : * Rectal exam * Stool leukocytes, culture, * Giardia antigen, Entamoeba histolytica antigen * CBC * Electrolytes * AST/ALT/bilirubin/alkaline phosphatase * Viral hepatitis serologies

Question 45

What is your differential diagnosis and workup plan for this patient : " 30 yo F presents with watery diarrhea, abdominal cramping, and bloating. Her symptoms are aggra- vated by milk ingestion and are relieved by fasting"

Answer 45

* Differential diagnosis : * Lactose intolerance * Gastroenteritis * Inflammatory bowel disease * Irritable bowel syndrome * Hyperthyroidism * Workup plan : * Rectal exam * Stool leukocytes and culture * **Hydrogen breath test** * TSH

Question 46

What is your differential diagnosis and workup plan for this patient : "33 yo M presents with watery diarrhea, diffuse ab- dominal pain, and weight loss within the past 3 weeks. He has a history of aphthous ulcers. He has not responded to antibiotics"

Answer 46

* Differential diagnosis : * **Crohn’s disease** * Gastroenteritis * Ulcerative colitis * Celiac disease * Pseudomembranous colitis * Hyperthyroidism * Small bowel lymphoma * Carcinoid syndrome * Workup plan : * Rectal exam, stool for occult blood * Stool leukocytes and culture * CBC, Electrolytes * Colonoscopy CT—abdomen * TSH * Small bowel series * 5-HIAA

Question 47

Upper GI bleeding - key history ?

Answer 47

1. Amount ? 2. Duration ? 3. Context ? =\> after severe vomiting, alcohol ingestion, nosebleed ? 4. Associated symptoms - constitutional, nausea, abdominal pain, dyspepsia ? 5. Medications (especially blood thinners, NSAIDs, and corticosteroids) ? 6. History of : 1. PUD - peptic ulcer disease, 2. Liver disease, 3. Abdominal aortic aneurysm repair, 4. Easy bleeding ?

Question 48

Upper GI bleeding - key physical exam ?

Answer 48

1. Vital signs - including orthostatics 2. ENT 3. Heart and lung 4. Abdominal exam 5. Order rectal exam

Question 49

Blood in stool - key history ?

Answer 49

1. Melena vs. bright red blood (hematochezia) ? 2. Is it mixed with stool or rather on its surface ? 3. Amount ? Duration ? 4. Associated symptoms : constitutional, abdominal or rectal pain, tenesmus, constipation/diarrhea ? 5. Menstrual cycle ? 6. History of injury or trauma ? 7. History of similar symptoms ? 8. Prior colonoscopy ? 9. Medications (especially blood thinners) ? 10. History of : 1. Easy bleeding ? 2. Atherosclerotic vascular disease ? 3. Renal disease ? 4. Aortic valve disease ? 5. Liver disease ? 6. Alcoholism ? 7. Abdominal aortic aneurysm repair ? 11. Family history of colon cancer ?

Question 50

Blood in stool - key physical examination ?

Answer 50

1. Vital signs ± orthostatics; 2. Abdominal exam - inspect, auscultate, percuss, palpate; 3. Order rectal exam !

Question 51

Explain the following terms : hematemesis, hematochezia, melena, upper GI bleeding, lower GI bleeding ?

Answer 51

1. **Hematemesis** - Vomiting of bright red (fresh) blood or old "coffee-ground" material; 2. **Hematochezia** - Bright red blood, maroon blood, or clots per rectum; 3. **Melena** - Black, tarry, foul-smelling stools; 4. Upper GI bleeding (**UGIB**) - Bleeding that originates prox to the lig. of Treitz (esophagus, stomach, duodenum). Manifests in 3 ways: (1) hematemesis, (2) melena, (3) hematochezia; 5. Lower GI bleeding (**LGIB**) - Bleeding that originates distal to the lig. of Treitz. Manifested by hematochezia;

Question 52

List common and uncommon caues of UGIB.

Answer 52

1. Mucosal abnormalities - small mucosal breaks (after NSAID's), stress gastritis; 2. Peptic ulcers - H.pyroli, NSAID's; 3. Esophageal inflammation - esophagitis, 2nd to reflux, medication, infection; 4. Gastroesophageal varices; 5. Angiodysplasia or vascular ectasias; 6. Mallory-Weiss tear; 7. Gastric antral vascular ectasia; 8. Portal hypertensive gastropathy; 9. Tumors; 10. Dieulafoy lesion; 11. Aortoenteric fistula; 12. Hemobilia; 13. Hemosuccus pancreaticus 14.

Question 53

List possible causes of lower GI bleeding (LGIB).

Answer 53

1. Diverticulosis; 2. Angiodysplasia or vascular ectasia; 3. Colorectal malignancy/postpolypectomy hemorrhage; 4. Colitis - ischemic colitis; 5. Infectious colitis - dysentery caused by Shigella, Campylobacter, Salmonella, Escherichia coli O157:H7 infection; 6. Inflammatory bowel disease; 7. Anorectal causes - hemorrhoids, rectal varices, anal fissures; 8. Stercoral ulcers = rectal ulcerations caused by chronic constipation; 9. Radiation proctitis; 10. Meckel's diverticulum; 11. NSAID-induced ulcers;

Question 54

List questions you should ask to a patient with GI bleeding.

Answer 54

1. Describe what you saw in the toilet bowl. 2. Have you had vomiting, if so, describe what it looked like. 3. When did you first noticed the bleeding ? 4. How many times have you had hematochezia or vomiting ? 5. Have you been passing or vomiting cups of blood or only streaks or small clots? 6. When was the last time you passed a black or bloody stool ? 7. Do you have any dizziness ? 8. Obtain the patient's vital signs (blood pressure and pulse) while supine. If normal, obtain vital signs after patient assumes a sitting or standing position. 9. Ask about associated symptoms : * vomiting, retching =\> Mallory-Weiss tear; * heartburn =\> erosive esophagitis; * odynophagia =\> esophagitis - pill-induced or infectious; * dysphagia =\> esophageal neoplasm, GERD with stricture; * dyspepsia =\> PUD or erosive gastritis; * chronic liver disease =\> esophageal varices, gastric varices , portal gastropathy; * dysentery =\> infectious diarrhea, inflammatory bowel disease; * straining with defecation, constipation =\> neoplasm, hemorrhoids, stercoral ulcer; 10. Ask about PMH : PUD, surgeries, HIV, neoplasms, diverticulosis, IBD, radiation tx, CAD, DM, CKD, ostearthritis, chronic liver disease, biopsy ? 11. Ask about medications - pay special attention to any blood thinners, NSAIDs, aspirin, immunosupressants, antibiotics; 12. SH : immigrant ? alcoholic ? travel history ?

Question 55

What is your differential diagnosis and workup plan for this patient : "45 yo F presents with **coffee-ground emesis** for the past 3 days. Her **stool is dark and tarry**. She has a history of **intermittent epigastric pain** that is relieved by food and **antacids**"

Answer 55

* Differential diagnosis : 1. Bleeding peptic ulcer 2. Gastritis 3. Gastric cancer 4. Esophageal varices * Workup plan : * Rectal exam * Upper GI endoscopy with biopsies and H. pyroli test * CBC, type and cross * LFT : AST, ALT, ALP, bilirubin * INR, aPTT, PT * Electrolytes, BUN, Creatinine, Glucose

Question 56

What is your differential diagnosis and workup plan for this patient : "40 yo F presents with **epigastric pain** and **coffee- ground emesis**. She has a history of rheumatoid ar- thritis that has been treated with **NSAIDs**. She is an **alcoholic**"

Answer 56

* Differential diagnosis : 1. Hemorrhagic gastritis 2. Alcohol-induced gastitis 3. Esophageal or gastric varices 4. Portal gastropathy 5. Bleeding from peptic ulcer 6. Gastric cancer 7. Mallory-Weiss tear * Workup plan : * Rectal exam * Upper GI endoscopy - Esophagogastroduodenoscopy * CBC, type and cross * Electrolytes * LFTs : AST, ALT, Alkaline phosphatase, bilirubin * INR * Albumin, total protein

Question 57

What is your differential diagnosis and workup plan for this patient : "67 yo M presents with **blood in his stool, weight loss, constipation**. He has a family history of colon cancer" ?

Answer 57

* Differential diagnosis : * Colorectal cancer * Anal fissure * Hemorrhoids * Diverticulosis * Ischemic bowel disease * Angiodysplasia * Bleeding from polyp * Inflammatory bowel disease - CU or CD * Workup plan : * Rectal exam * CBC * AST/ALT/bilirubin/alkaline phosphatase * INR * Colonoscopy * CEA * CT—abdomen/pelvis

Question 58

What is your differential diagnosis and workup plan for this patient : "33 yo **F** presents with **rectal bleeding and diarrhea** for the past _week_. She has had **lower abdominal pain and tenesmus** for several months"

Answer 58

* Differential diagnosis : * Ulcerative colitis * Crohn's disease * Proctitis * Anal fissure * Hemorrhoids * Diverticulosis * Dysentery * Anorectal dysfunction * Workup plan : * Rectal exam * CBC * PT/PTT * Colonoscopy CT—abdomen/pelvis

Question 59

What is your differential diagnosis and workup plan for this patient : "58 yo M presents with painless bright red blood per rectum and chronic constipation. He consumes a low-fiber diet"

Answer 59

* Differential diagnosis : 1. Diverticulosis 2. Anal fissure 3. Hemorrhoids 4. Angiodysplasia 5. Colorectal cancer * Workup plan : * Rectal exam * CBC, type and cross * PT/PTT * Electrolytes * Colonoscopy * Tagged RBC scan * CT—abdomen/pelvis

Question 60

Hematuria - key history ?

Answer 60

1. Amount ? 2. Duration ? 3. Presence of clots ? 4. Point along the stream : blood at the beginnig or at the end or throughout ? 5. Associated symptoms : 1. Constitutional - fever, chills, weight loss, night sweats, cough, nasal congestion ? 2. Renal colic ? 3. Dysuria ? 4. Irritative voiding symptoms ? 6. Medications ? 7. History of vigorous exercise ? 8. Trauma ? 9. Smoking ? 10. Stones ? 11. Cancer ? 12. Easy bleeding ? 13. Skin bruising (purpura) ?

Question 61

Hematuria - key physical exam ?

Answer 61

1. Vital signs; 2. Lymph nodes; 3. Abdominal exam; 4. Genitourinary and rectal exams; 5. Extremities.

Question 62

Name possible causes for hematuria.

Answer 62

1. Urologic cancer : bladder, renal, prostate, ureteral 2. Common benign lesions : 1. Nephrolithiasis =\> Stones 2. Renal disease 3. UTI =\> Infection 4. Prostatic hyperplasia 3. HITTERS : **Hematologic** or coagulation disorders, **Infection**, Trauma, **Tumor**, Exercise, **Renal disorders**, **Stones**

Question 63

Name possible causes for hematuria - glomerular and nonglomerular !

Answer 63

* Nonglomerular : * Lower urinary tract source : * urethritis, * prostatitis * benign prostatic hypertrophy * cystitis * bladder carcinoma * prostate carcinoma * exercise induced * Upper urinary tract source : * ureteral calculus, renal calculus * hydronephrosis * pyelonephritis * polycystic kidney disease * hypercalciuria, hyperuricosuria * renal trauma * pappilary necrosis * interstitial nephritis * sickle cell trait or disease * renal infarct * renal tuberculosis * infection with Schistosoma haematobium * renal vein thrombosis * Glomelular * Primary glomerulonephritis : IgA nephropathy, postinfectious, idiopathic; * Secondary glomerulonephritis : SLE, Wegener's granulomatosis; * Familial : Thin basement membrane disease, Hereditary nephritis - Alport's;

Question 64

List questions you will ask to a patient presenting with hematuria.

Answer 64

1. Were you ever told that there was blood in your urine ? 2. Have you ever had diagnostic tsting done to evaluate blood in your urine ? 3. Describe an episode of seeing blood in your urine. 4. When was your LMP ? Are you having your menstrual period ? 5. Have you had any traumas or injuries ? Have you had a recent injury to your abdomen, back, or flank? 6. Have you had any recent UTI ? 7. Have you been having any burning during urination, pain during urination, discomfort ? 8. Do you do sports ? Did you exercise vigorously before you noticed blood in your urine ? 9. Is this the first episode of blood in your urine? 10. Have you recently had a urinary catheter in place, a urologic procedure, or a urinary tract infection? 11. Have you had any infections recently, before you saw blood in your urine ? 12. Does the urine contain clots ? Do the clots look like pipes ? Are the clots bulky and look like balls ? 13. Is blood present : at the beginning of urine stream ? At the end of voiding ? Throughout urination ? 14. Had you had fevers or felt feverish? 15. Do you have pain or burning on urination ? 16. Do you have a pain in your lower belly ? Can you describe this pain for me ? 17. Do you have back pain ? 18. Do you have to go to the bathroom more often ? Do you have to wake up in the night to urinate ? 19. Have you ever taken any medications ? 20. Have you ever been diagnosed with kidney stones, gout, sickle cell anemia / sickle cell trait ?

Question 65

What is your differential diagnosis and workup plan for this patient ? "65 yo M presents with **painless hematuria**. He is a **heavy smoker** and works as a **painter**"

Answer 65

* Differential diagnosis : * Bladder cancer * Renal cell carcinoma * Nephrolithiasis * Acute glomerulonephritis * Prostate cancer * Coagulation disorder * Pappilary necrosis * Acute kidney injury * Workup plan : * CBC with differential * Basic metabolic panel : electrolytes, glucose, ABGs, BUN, creatinine * Urinalysis, urine culture * INR/PT, aPTT * PSA * Prostate and genital exam * CT - abdomen, pelvis

Question 66

What is your differential diagnosis and workup plan for this patient : "35 yo M presents with **painless hematuria**. He has a family history of **kidney disease**"

Answer 66

* Differential diagnosis : 1. **Polycystic kidney disease** 2. Nephrolithiasis 3. Acute glomerulonephritis - IgA nephropathy 4. UTI 5. Alport syndrome, Thin basement membrane syndrome 6. Secondary glomerulonephritis 7. Bladder carcinoma, Renal cell carcinoma * Workup plan : * Genitourinary exam UA, urine cytology * BUN/Cr * PSA * CBC * PT/PTT * U/S—renal * CT—abdomen/pelvis

Question 67

What is your differential diagnosis and workup plan for this patient : "55 yo M presents with **flank pain** and **blood in his urine** without dysuria. He has experienced **weight loss and fever** over the past 2 months. Exam reveals a **flank mass**"

Answer 67

* Differential diagnosis 1. Renal cell carcinoma 2. Bladder cancer 3. Nephrolithiasis 4. Acute GN 5. Pyelonephritis 6. Prostate cancer 7. Advanced stage of PKD * Workup plan : * Genitourinary, rectal exams * UA, urine cytology * BUN/Cr * PSA * CBC * PT/PTT * U/S—renal * CT—abdomen/pelvis * Cystoscopy

Question 68

Key history - urinary complaints

Answer 68

1. Duration; 2. Obstructive symptoms (hesitancy, diminished stream, sense of incomplete bladder emptying, straining, postvoid dribbling); 3. Leakage with cough or sneeze, incontinence ? 4. Irritative symptoms (urgency, frequency, nocturia); 5. Constitutional symptoms; 6. Bone pain; 7. Medications; 8. History of UTIs; 9. Urethral stricture; 10. Urinary tract instrumentation; 11. Stones, diabetes, alcoholism ?

Question 69

Physical examination - urinary problems ?

Answer 69

1. Vital signs; 2. Abdominal exam (including **suprapubic percussion** to assess for a distended bladder); 3. Genital and rectal exams; 4. Focused neurologic exam.

Question 70

Define : Acute dysuria, Internal dysuria, External dysuria.

Answer 70

* Dysuria = **pain, burning, or discomfort** experienced during or immediately after urination; * Acute dysuria = dysuria of **less than 1 week** in duration; * Internal dysuria = dysuria that is localized to the internal genital structures (urethra, bladder, suprapubic area); * External dysuria = dysuria that is localized to external genital structures (labia minora and majora) and occurs as urine exits the body;

Question 71

Define : urgency, frequency, nocturia.

Answer 71

1. Urgency = **sudden need** to urinate that is often accompanied by **bladder discomfort** and the **inability to void** more than a minimal quantity of urine; 2. Frequency = urinating more frequently than usual without an increase in total urine volume due to the bladder's decreased capacity to hold urine; 3. Nocturia = waking up to urinate 2 or more times during the night;

Question 72

Define : voiding symptoms and storage symptoms.

Answer 72

1. Voiding symptoms - symptoms that occur at the **time of urination**. These include : 1. slow or intermittent urine stream, 2. difficulty initiating urination (**hesitancy**), 3. prolonged termination of urination (**dribbling**) 4. dysuria - pain, burning, or discomfort experienced during or immediately after urination; 2. Storage symptoms : symptoms that occur during bladder storage and filling. These include : 1. urinary urgency or frequency, 2. nocturia, 3. incontinence.

Question 73

Recall possible causes of dysuria.

Answer 73

* Infection : 1. Bacterial urethrocystitis 2. Urethritis due to Chlamydia trachomatis 3. Urethritis due to Neisseria gonorrhoea 4. Pyelonephritis 5. Prostatitis (acute and chronic) 6. Epididymitis * Inflammation 1. Atrophic vaginitis 2. Irritant or allergic reactions 3. Lichen sclerosis 4. Lichen planus 5. Vulvovestibulitis (vulvodynia) 6. Reactive arthritis 7. Behçet's syndrome 8. Urethral or vesicular calculi 9. Painful bladder syndrome/interstitial cystitis 10. Radiation 11. Drug side effects (chemotherapy, dopamine) * Mechanical 1. Cystocele 2. Urethral stricture 3. Bladder neck obstruction (benign prostatic hyperplasia) 4. Urinary catheter insertion * Neoplasm 1. Cancers of the penis, prostate, vagina, bladder 2. Metastatic cancers * Referred : 1. Shingles/postherpetic neuralgia 2. Sacral nerve compression or injury (osteoarthritis, degenerative disk disease, spinal stenosis) 3. Pudendal nerve injury (childbirth or pelvic surgery) 4. Neurologic 5. Multiple sclerosis 6. Neurofibromatosis 7. Parkinson's disease/multiple system atrophy * Hormonally mediated =\> Endometriosis

Question 74

How will you start your dysuria encounter - what questions will you ask ? What is important to remeber before you actually start the encounter ?

Answer 74

* Start with questions evaluating UTI; * Elicit a sexual history. 1. Tell me about your symptoms. 2. I will need to ask some questions about your sexual practices **to help me find out what's causing your symptoms**. Are you currently sexually active (or having sex) ? 3. "These are questions I ask all my patients" 4. "Remeber that everything you say is confidential" 5. How many sexual partners have you had in the past year ? 6. Do you have sex with men, women, or both ?

Question 75

What are some elements you need to evaluate during an inteview with a patient presenting with dysuria. Give examples of questions you will ask.

Answer 75

1. Focus on symptom **location, onset, duration;** 2. **Ask about ​associated** urinary, genital, pelvic, and systemic symptoms; 3. Ask about symptoms that support the diagnosis of UTI =\> recent-onset dysuria, urinary urgency, frequency, nocturia, suprapubic pain, cloudy urine; 4. Ask about PMH including past UTIs, STDs ! 5. In sexually active patients consider STDs; 6. Ask about vaginal/cervical/urethral discharge and hematuria ! 7. Ask about pelvic, urologic, or back surgeries; 8. In women, include a gynecologic history. 9. An older individual ? =\> explore factors that may increase the risk of UTI (atrophic vaginitis, benign prostatic hyperplasia, chronic prostatitis, urinary tract instrumentation); 10. Questions to ask : * When urinating, do you experience **burning sensation**, as if the urine were hot ? * Are you urinating more **frequently** than usual during the day ? * Do you feel a **strong sensation** that you need to urinate immediately ? * Have you been **treated** for a urinary tract infection in the past ? * Did your symptoms improve after treatment with **antibiotics**? * How do your **current** symptoms compare to those you had in **the past**?

Question 76

What are alarm symptoms you must evaluate in a patient with dysuria ? What is their importance ?

Answer 76

1. Fever or chills = urosepsis ? 2. Flank pain = pyelonephritis ? 3. Flank pain with hematuria =\> renal cancer ? 4. Painless hematuria =\> bladder cancer ? 5. Penile discharge, mass or ulcer, pain at tip of penis =\> penile cancer ? 6. Pelvic pain, dyspareunia =\> endometriosis, PID ? 7. Painful oral ulcers, arthritis, eye findings =\> Behcet syndrome, Reactive arthritis ? 8. Painful genital ulcers ? =\> Behcet's syndrome; 9. Suprapubic pain, incontinece, obstructive urinary symptoms ? =\> neurologic disease ? - MS, PD

Question 77

What focused questions will you ask in an encounter with a patient c/o dysuria ?

Answer 77

1. How long have you had pain with urination ? 2. Is the pain associated with your menstrual cycle ? 3. Did your symptoms start after having sex ? 4. At what point during urination does your pain occur ? 5. Does your pain get worse after you consume certain foods or drinks ? 6. Does your pain increase when your bladder is full and improve after urination ? 7. Do you urinate more frequently than usual during the day ? 8. Do you have an intense sensation of needing to urinate immediately ? 9. Is the urge to urinate so immediate that you sometimes urinate before you can get to the bathroom ? 10. Is the amount of urine with each episode less than usual ? 11. Has the appearance of your urine changed ? 12. Does your urine smell of ammonia ? 13. Is your urinary stream weaker than usual ? 14. Does it take longer than usual to begin urination ? 15. Do you experience dribbling or slow urine flow at the end of urination ? 16. Do you have flank pain or nausea and vomiting ? 17. Are your testicles painful or swollen ? 18. Do you have rectal discomfort, pain, discharge ? 19. Have you noticed any swollen lymph nodes in your groin area or new headaches ? 20. Have you noticed any blood in your urine ? 21. Are you having pain in your mid-back (flank pain) ? 22. Do you have a vaginal discharge ? 23. What color is the discharge ? 24. Do you have burning or pain in your external genital area ? 25. Do you have lower abdominal pain or vaginal bleeding ? 26. Is the discharge bloody ? 27. Have you felt more tired than usual ? Have you been losing weight without trying ? 28. Have you had joint aches, mouth ulcers, or eye symptoms ? 29. Have you had painful genital ulcers ? 30. Have you felt vaginal dryness ? 31. Do you feel discomfort or the sensation of something in your vagina when you urinate ? 32. Are you sexually active ? 33. Do you have a new sexual partner ? 34. How many times have you had sexual intercourse in the past week ? 35. Is sexual intercourse painful ? 36. What do you use to prevent pregnancy ? 37. Do you have sex with men ? 38. Tell me about any surgeries you have had. 39. Have you recently had any bladder procedures or had a urinary catheter placed ? 40. Did you ever smoke cigarettes? What jobs have you held? 41. Have you ever lived or traveled in the Middle East, North or sub-Saharan Africa, or India?

Question 78

What are the 3 most common diagnosis made in patients with flank pain ?

Answer 78

1. Nephrolithiasis 2. Pyelonephritis 3. Musculoskeletal strain

Question 79

Give differential diagnosis of flank pain.

Answer 79

1. Nephrolithiasis 2. Pyelonephritis 3. Musculoskeletal strain 4. Herpes zoster 5. Papillary necrosis 6. Renal abscess 7. Renal infarct - cardioembolic 8. Renal vein thrombosis 9. Adult Polycystic Kidney Disease 10. AAA 11. Retroperitoneal hemorrhage 12. Pulmonary embolism 13. Pneumonia - lower lobe 14. Pleural effusion of empyema 15. Subphrenic abscess 16. Biliary tract disease - gallbladder 17. Diverticulitis, appendicitis, psoas abscess 18. Vertebral compression fracture 19. Retroperitoneal malignancy 20. Malingering 21. Bacterial endocarditis with splenic infarction 22. Renal tuberculosis 23. Retroperitoneal fibrosis 24.

Question 80

How will you start an interview with a patient presenting with flank pain ? What will you keep in mind even before you begin your encounter ?

Answer 80

1. Onset, location, duration, quality, associated features of the pain; 2. Similar pain before ? 3. Medical conditions that predispose to renal stone formation =\> hyperparathyroidism, mmyeloproliferative disorders, renal tubular acidosis; 4. Occupational history and substance use or abuse history ? 5. Tell me about the pain you are having. 6. Did the pain come on suddenly or gradually ? 7. Where in your body did you first notice the pain ?

Question 81

About what associated symptoms should you ask patient presenting with flank pain ? What alarming symptoms should you have in mind - what can they indicate ?

Answer 81

* Associated symptoms : nausea and/or vomiting, fever, hematuria; * Confusion and fever =\> urosepsis, cholecystitis, pneumonia; * Orthostatic dizziness =\> AAA, hemorrhage; * Use of anticoagulants =\> retroperitoneal hemorrhage; * Pleuritic chest pain =\> PE, pneumonia, subphrenic abscess, pleurisy or muscle strain; * Associated abdominal pain =\> AAA, subphrenic abscess, pancreatitis; * Weight loss =\> malignancy; * Slow onset and failure to resolve =\> malignancy; * Prolonged fever with sudden-onset flank pain =\> endocarditis with septic emboli; * Sudden onset of flank pain =\> AAA, Nephrolithiasis, Retroperitoneal hemorrhage, Pulmonary embolism, Renal infarct;

Question 82

A patient has : flank pain + IVDA =\> what do you think ?

Answer 82

Injection drug abuse is a "red flag" in all patients with flank pain =\> such patients require a more careful evaluation for **_endocarditis_**.

Question 83

What is your differential diagnosis and workup plan ? "60 yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has had 2 episodes of urinary retention that required catheterization"

Answer 83

* Differential diagnosis : 1. Benign prostatic hypertrophy (BPH) 2. Prostate cancer 3. UTI 4. Bladder stones * Workup plan : 1. Rectal exam 2. UA 3. CBC 4. BUN/Cr 5. Alkaline phosphatase 6. U/S—prostate (transrectal) 7. PSA

Question 84

What is your differential diagnosis and workup plan ? "71 yo M presents with nocturia, urgency, a weak stream, terminal dribbling, hematuria, and **lower back pain** for the past 4 months. He has also experienced weight loss and fatigue"

Answer 84

* Differential diagnosis : * Prostate cancer * BPH * Renal cell carcinoma * UTI * Bladder stones * Workup plan : * Rectal exam * UA, CBC, BUN/Cr * PSA * U/S—prostate (transrectal) * Prostate biopsy * Alkaline phosphatase * CT—pelvis, MRI—spine

Question 85

What is your diagnosis and workup plan ? "18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner"

Answer 85

* Differential diagnosis : * Urethritis * Cystitis * Prostatitis * Workup plan : * Genital, rectal exams * UA, urine culture * Gram stain and culture of urethral discharge * Chlamydia and gonorrhea PCR

Question 86

What is your differential diagnosis and workup plan ? "45 yo diabetic F presents with dysuria, urinary fre- quency, fever, chills, and nausea for the past 3 days. There is left CVA tenderness on exam"

Answer 86

* Differential diagnosis : * Acute pyelonephritis * Nephrolithiasis * Lower UTI (cystitis, urethritis) * Renal cell carcinoma * Workup plan : * UA, urine culture and sensitivity * Blood culture * CBC * BUN/Cr * U/S—renal * CT—abdomen

Question 87

What is your differential diagnosis and workup plan ? "55 yo F presents with urinary leakage after exercise. She loses a small amount of urine when she coughs, laughs, or sneezes. She also complains of vague low back pain. She has a history of multiple vaginal de- liveries, and her mother had the same problem after the onset of menopause"

Answer 87

* Differential diagnosis : * Stress incontinence * Mixed incontinence * Urge incontinence * Overflow incontinence * Functional incontinence * UTI * Diabetes mellitus * Workup plan : * UA, urine culture * BUN/Cr * Urodynamic testing * IVP * Cystourethroscopy

Question 88

What is your differential diagnosis and workup plan ? "33 yo F presents with urinary leakage. She is unable to suppress the urge to urinate and loses large amounts of urine without warning. She has a history of UTIs and a family history of diabetes mellitus. She drinks 8 cups of coffee per day. She has been under stress since her sister passed away a few months ago"

Answer 88

* Differential diagnosi : * Urge incontinence * Mixed incontinence * Stress incontinence * Overflow incontinence * Functional incontinence * UTI * Diabetes mellitus * Workup plan : * CBC, Electrolytes, BUN/Cr, glucose * UA, urine culture * Urodynamic testing * IVP * Cystourethroscopy

Question 89

What types of urinary incontinence do you know ?

Answer 89

1. Stress incontinence 2. Urge incontinence 3. Mixed incontinence 4. Detrusor disinhibition incontinence 5. Functional incontinence

Question 90

Explain urge incontinence

Answer 90

Urge incontinence is caused by an **involuntary detrusor contractions** which cause an **urgent** need to void. After a variable **latency period**, the contractions **exceed** bladder outlet resistance (normally produced by the intenal sphincter), resulting in incontinence.

Question 91

Explain the mechanism of how detrussor disinhibition results in incontinence.

Answer 91

Spontanous triggering of the **spinal reflex voiding mechanism** when bladder reaches a _threshold_ volume and there is **inadequate inhibition** of bladder contractions by the CNS; Urine loss may occur with or _without_ warning !

Question 92

Explain the machanism of stress incontinence.

Answer 92

Leakage caused by an increase in intra-abdominal pressure, as produced by a cough, sneeze, laughing, standing up, or heavy lifting. Also called sphincter incompetence.

Question 93

Explain what DHIC means and what overflow is ?

Answer 93

* DHIC - Detrusor Hyperactivity with Impaired Contractility =\> despite an overreactive bladder, detrusor contractions are ineffective, resulting in bladder distention and overflow incontinence; * Overflow - due to urinary retention, pressure in the bladder exceeds outlet (sphincter) resistance causing leakage until the bladder pressure drops below the outlet resistance.

Question 94

Explain functional and mixed incontinence.

Answer 94

1. Mixed incontinence : incontinecne form multiple etiologies, most commonly stress and urge; 2. Functional incontinence : incontinence despite a normaly functioning bladder due to the inability to reach a toilet in time;

Question 95

List questions one should ask in an incontinence encounter.

Answer 95

1. Tell me about any troubles you are having with your bladder. 2. Tell me about any trouble you're havinh holding your urine/water. 3. In the last 6 months, have you lost your urine when you didn't want to ? 4. In the last 6 months, have you had to wear a pad or a protective undergarment to catch your urine ? 5. In the last 6 months, have you awoken in the morning with a damp nightgown or bedclothes ? 6. When does it occur ? How long has it been occuring and has it been getting worse ? 7. Are there associated activities, movements, circumstances related to urinary accidents ? 8. Are there any warning signs ? 9. What is the severity ? frewuency ? pattern ? 10. Ask about : plvic surgeries, radiation, obsetric history, traumas; 11. Associated symptoms : urinary, fluid intake ? 12. Medication list, PMH ? 13. How do you handle your problem ? 14. What worries you most ? 15. What do you expect from treatment ?

Question 96

What alarm symptoms should you bear in mind during the incontinence interview ?

Answer 96

1. In older or developmentally disabled patients =\> 1. Urinary tract or other **infection;** 2. Acute **metabolic** disturbance; 3. **Stroke**, myocardial infarction, or other acute medical condition 2. Continuous leakage =\> 1. Severe urinary **retention with overflow;** 3. UI with dysuria =\> 1. Bacterial cystitis, urethritis from **STD**; 2. **Atrophic** urethritis from estrogen deficiency; 3. Nonbacterial **cystitis**; 4. UI with gross hematuria =\> 1. **Hemorrhagic** cystitis; 2. Bladder or urethral **cancer**; 5. UI with polyuria : 1. **Metabolic** disturbance (hyperglycemia, hypercalcemia); 6. UI with **fecal matter** or **large air bubbles** excreted during urination =\> 1. Vesicorectal (or vesicosigmoid) **fistula** resulting from pelvic carcinoma, inflammatory bowel disease, or previous pelvic irradiation; 7. Consistent loss of urine in upright posture or with any action that produces a minimal increase in intra-abdominal pressure, despite bladder not feeling full =\> Incompetent urethral sphincter or severe pelvic floor collapse;

Question 97

What focused questions will lead you to diagnosis ?

Answer 97

1. Do you leak urine, wet yourself, or wet your pads or undergarments... : When you cough or sneeze? When you bend down or lift something up? When you walk quickly, jog, or exercise? While you are undressing to use the toilet? When you delay going to the toilet immediately after first feeling the need to urinate? 2. Do you get such a strong and uncomfortable need to urinate that you leak (even small drops) or wet yourself before reaching the toilet? 3. Do you have to rush to the bathroom because you feel a sudden, strong need to urinate? 4. Do you experience a warning (urge to urinate)? Is the warning at least 1 minute before you leak urine? 5. Do you ever leak urine while seated or lying without realizing it until later? 6. Are you unable to feel your bladder getting full before you experience a leakage of urine? 7. When you leak urine, how large is the amount? 8. Did the difficulty controlling your urine start or significantly worsen fairly suddenly, over hours to days? 9. Did the difficulty controlling your urine come on gradually, over weeks to months? 10. Is it painful to urinate? 11. Do you need to go frequently (urinary frequency)? 12. On average, how long is the interval between leakages? 13. Do you have constipation (eg, last bowel movement 3 or more days ago)? 14. Do you need to strain or push to begin your stream? 15. Is there a significant delay between trying to urinate and the urine starting to flow? 16. Is your stream weak or do you dribble? 17. When you urinate, do you feel that you are unable to completely empty your bladder? 18. How many children have you had by vaginal delivery? 19. Do you usually experience pressure in the lower abdomen? 20. Do you usually experience pain in the lower abdomen or genital area? 21. Do you usually experience heaviness or dullness in the pelvic area? 22. Do you usually have a sensation of bulging or protrusion from the vaginal area? 23. After finishing urinating, do you need to return to the toilet in a few minutes because you feel the need to void again? If yes and you void again, what is the amount? 24. Is the incontinence worse during the day or night? 25. Have you started a new medication or increased the dose?