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1
Q

Haematuria history HPC

A

HPC == CLots

  • CLarify exactly when, colour, beetroot?
  • Onset when did you first notice it
  • Timing always there or come and go
  • Severity do you pass any clots
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2
Q

Haematuria history associated symptoms

A

Associated symptoms

  • Pain == SOCRATES
  • Frequency , has this changed do you have sudden urge
  • Nocturia
  • Urinary stream
  • Constitutional , any general unwellness
  • Renal failure , gained weight, swollen ankles
  • Glomerulonephritides, sore throat, rashes, joint ache
  • Pulmonary- renal conditions , coughed up blood
  • Trauma , stomach, groin trauma

ICE

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3
Q

Haematuria history SHX, PMH, DHX etc

A

PMH

  • UTI, prostate renal bladder cancer
  • BPH
  • Diabetes
  • HTN
  • Catheter

Drug history

  • Any regular meds
  • Allergies

Family history

  • Renal disease
  • PKD
  • Haematuria

SHX

  • Smoke
  • Worked with industrial chemicals or dyes
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4
Q

Important points haematuria

A

Always clarify colour
Clots = unlikely to be glomerular cause
Always clarify timing (initial, middle, terminal)
Poor stream suggests obstruction

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5
Q

Haematuria DDX considerations

A

Gross or microscopic

Gross- tends to be lower lesion higher likelihood of malignancy so investigated more vigorously

Microscopic is more common and only warrants further investigation if recurring or associated with UTI symptoms

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6
Q

Haematuria DDX Carcinoma

A

Renal cell carcinoma

  • triad of flank pain, haematuria and abdominal mass
  • constitutional symptoms
  • May present with paraneoplastic syndrome excess renin, parathyroid hormone and EPO

TCC

  • Painless intermittent haematuria in older males, worrying sign
  • Working with industrial dyes, smoking
  • Schistosomiasis
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7
Q

Haematuria DDX renal calculi

A

Renal calculi

  • Classic acute excruciating pain radiates from loin to groin, with N&V
  • Men in 30’s- 50’s
  • Pain is more constant than biliary colic, but can have period of dull ache
  • Most cases are actually found asymptomatically
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8
Q

Haematuria DDX UTI

A

Cystitis

  • typically urinary frequency, urgency and pain
  • fever
  • urethral discharge
  • Cloudy and foul odour urine
  • More common in women and elderly, may just have delirium
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9
Q

Haematuria DDX glomerulonephritis

A 
Many different causes 
may have preceding URTI, streptococcal nephropathy
IgA nephropathy 
Haemoptysis - Goodpastures
Rash and systemic features- vasculitis
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10
Q

Management haematuria

A

frank haematuria requires urgent referral to urology

bladder cancer = transurethral resection for superficial tumours

RCC- nephrectomy

Renal calculi - < 5mm usually pass on own, extracoporeal lithotripsy or endoscopic removal for medium stones

Nephrotic syndrome- treat cause eg furosemide, acei ccb to control fluid retention

Rapidly progressive glomerulonephritis, high dose steroids and cyclophosphamide

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11
Q

Dysuria HPC and urinary history

A

o’ SOCRATES

Frequency - and volume passed
Urgency 
Colour, blood
Discharge, colour, volume, smelly= sexual history 
Fever
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12
Q

Urological history men and women

A

Men

  • Urinary stream , start, power, dribbling
  • Nocturia
  • Prostatitis- ejaculation painful?

Women

  • Menopause?
  • Dysmenorrhoea
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13
Q

Dysuria abdo history

A

Abdo pain - socrates
Calculi - stones?
Painful bowel motions
Diarrhoea

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14
Q

Dysuria PMH, SHX, DH etc

A

PMH

  • UTI, STI, renal calculi
  • arthritis and conjuctivitis
  • Catheter

DH

  • Medications
  • allergies

SHX

  • does your partner have any similar symptoms
  • Occupation
  • Smoking and drinking
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15
Q

Dysuria overview

A 
o SOCRATES
urinary history
male/female
abdo
PMH etc
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16
Q

Haematuria overview

A

HPC clots
Associated symptoms
PMH etc

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17
Q

Dysuria important points

A

Always tailor history to the individual eg 20 yo vs 60 yo
Pain at start suggests urethritis
Pain at the end suggests cystitis

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18
Q

DDX dysuria UTI

A

Cystitis

  • typically urinary frequency, urgency and pain
  • fever
  • urethral discharge
  • Cloudy and foul odour urine
  • More common in women and elderly, may just have delirium
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19
Q

DDX dysuria pyelonephritis

A

Very unwell, fever rigors nausea and vomiting flank pain radiates to the back
Dysuria, frequency, urgency etc may be present

20
Q

DDX dysuria STI

A

discharge common
history of new partner or unprotected sex
history of painful sex, painful ejaculation, prostatitis
Symptoms of reactive arthritis

21
Q

DDX dysuria endometriosis

A

Cyclical pelvic pain which crescendos before menstruation and then dissipates
Dyspareunia, dysmenorrhoea, subfertility

22
Q

DDX dysuria renal calculi

A

Renal calculi

  • Classic acute excruciating pain radiates from loin to groin, with N&V
  • Men in 30’s- 50’s
  • Pain is more constant than biliary colic, but can have period of dull ache
  • Most cases are actually found asymptomatically
23
Q

DDX dysuria BPH

A

Urinary frequency and nocturia with obstructive symptoms = hesitancy, weak stream and dribbling
Incomplete bladder emptying causes continuous urge to go
Dysuria secondary to UTI due to urinary stasis

24
Q

Dysuria management

A

UTI - trimethoprim
Pyelonephritis - antibiotics
STI - refer to GUM give one off AB and start contact tracing
BPH - alpha blockers to relax sphincters and 5 alpha reductase inhibitor (reduce androgen ADT)

25
Polyuria HPC
Urinary history - Onset - frequency - Nocturia - Amount - Thirst - Dysuria - Haematuria and discharge - Urge incontinence
26
Polyuria urological history men and women
Men - urinary stream - prostatitis ejaculation and defaecation pain Women - Prolapse, dropping sensation from pelvis, anything protruding - Obstetric history complicated, large? - Menopause
27
Polyuria endo history
Abdo pain if so SOCRATES | Constitutional, weight loss, appetite, fever etc
28
Polyuria PHM etc
PMH - diabetes DH - diuretics - allergies FH - diabetes - renal conditions SHX - smoke - drink - alcohol
29
Polyuria overview
Urinary history Urological history men/women endo PMH etc
30
Polyuria important points
Polyuria is defined clinically as production of more than 3L urine in 24 hours this is very difficult to measure so may be best using a voiding diary
31
Polyuria DDX UTI
dysuria, frequency and urgency fever and discharge may be frothy with foul odour, may contain blood often in women and elderly with only delirium as presenting complaint
32
Polyuria DDX hyperactive bladder
severe urgency, nocturia, incontinence and frequency | Past history of neurological disease, eg Parkinsons, stroke, spinal cord disease
33
Genitourinary prolapse
older women multiple vaginal deliveries hysterectomy frequency, recurrent UTIs, stress incontinence, fullness sensation in vagina
34
Polyuria DDX BPH
frequency, nocturia and hesitancy = ( weak stream, trouble starting and terminal dribbling) incomplete bladder emptying gives continuous urge to go
35
Polyuria DDX Diabetes mellitus
Polydipsia, polyuria, abdominal pain, nausea and vomiting, pear drop breath in DKA Often family history
36
Polyuria DDX Diabets insipidus
Polydipsia and polyuria Huge quantities of very dilute urine Nocturia often present and bothersome No signs of infection, irritative disorder
37
Polyuria DDX
``` UTI vaginal prolapse Diabetes M Diabetes I Hyperactive bladder BPH ```
38
Haematuria DDX
``` Renal cell carcinoma Transitional cell carcinoma Renal calculi UTI Glomerulonephritis ```
39
Dysuria DDX
``` UTI Pyelonephritis BPH STI Endometriosis Renal calculi ```
40
Polyuria Management
Diabetes M- diet or insulin Diabetes I - careful regular fluids, step up to exogenous ADH DKA- fluid and electrolyte resus insulin until glucose level is controlled Genitourinary prolapse - vaginal pessaries, surgery to tighten up ligaments Hyperactive bladder- pelvic floor exercises, cut out caffeine and alcohol, botox if refractory Diuretics- take in morning if have to
41
Male genital exam steps
General inspection - skin, eyes, joints - lower abdomen, femoral and inguinal (bear down), scrotum bear down. Palpation standing - scrotum bear down and lumps swellings Palpation supine - testicle size, surface, mobility - epididymis - vas deferens - lumps/mass, palpate, tender, impulse, transillumabillity, cough impulse - penis - foreskin - meatus - frenulum - corona Lymph nodes - inguinal, sub inguinal, medial thigh Femoral pulses
42
Gyanecological exam steps
Intro - ask allergies, emptied bladder - position light, use latex free gloves Inspection - warts, ulcers, masses - vulvitis - prolapse, ask to bear down, and for stress incontinence - discharge - swelling Bimanual palpation - Lubricant - behind cervix and push up while pushing down on abdomen, size, shape and position, mobility - adnexae, masses and tenderness - cervix, tenderness, polyps, masses, consistency, closed/open os
43
Speculum examination steps
Warm speculum water/lubricant gel to speculum Inspect vagina - masses, swellings, warts, discharge Cervix - nulliparous, ectropion, masses, polyps - nabothian cysts (ecto growing over endo) - discharge - bleeding Swabs - take from endocervical and high vaginal Smear test ALWAYS WARN ABOUT SPOTTING / SLIGHT BLEEDING AFTERWARDS
44
Male catheterisation equipment
``` apron sterile gloves catheter pack catheter collection bag 50ml syringe 10ml water Instillagel antiseptic fluid ``` Have smaller catheter nearby 2x bins
45
Male catheterisation steps
Intro clean hands position patient put on apron unpack catheter pack put in catheter, syringe, water, collecting bag into sterile field pour in antiseptic gel wash hands put on sterile gloves Prepare equipment caps Expose patient put on sterile drape over penis hold penis with dirty hand, retract foreskin and clean with wipe Insert anaesthetic instillagel and wait 5 mins Introduce catheter tip and move in gradually with non touch technique Once fully in check urine outflow push on bladder and use syringe if necessary Inflate balloon Attach catheter bag Document notes

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