Flashcards in Week 2 - Lower abdominal pain and anuria Deck (4)
Mr. M.R. is a 74y retired carpenter who lives in Ingham. He attends the GP surgery suffering from lower abdominal pain and a history of having not passed urine since the day before.
Take a history of this patient.
• Dysuria, puffy face, backache - 36h.
- Dysuria - infection, stones.
- Puffy face - kidney disorders.
- Back ache - kidney pain if in loin area.
• Lower abdominal pain, suprapubic 8/10, no urine passed since last night.
• Urinary frequency (4-5/day; 2/night); terminal dribbling and hesitancy.
• Poor stream, cannot empty bladder. Urinary urge incontinence.
- Some obstruction. Urge but cannot pass → dribbling.
• Urinary symptoms… months, ‘maybe even a couple of years’.
• No fever, no haematuria, no h/o STD, bit tired, since 2005, diabetes.
• Smoker since age 16, 5-10/day, cough in mornings, early morning erections.
- Early morning erections - significance?
• If erection - normal testosterone, no neuropathy.
• DRE - firm enlarged prostate, suprapubic tenderness (bladder inflammation).
• Site of pain
• Character of pain
• Alleviating factors
• Timing - experienced before? Constant or intermittent? How long does it last? Worse at a particular time?
• Exacerbating factors
• Associated symptoms
• Effect on lifestyle
• Nausea, fatigue, oedema, pallor (acute renal failure)
• Haematuria, dysuria, frequency, urgency. Fever.
• Polyuria, polydipsia (diabetes)
• Weight loss, fatigue, loss of appetite (tumour)
• Diarrhoea, frequency (autonomic neuropathy).
• Incontinence, dribbling, retention.
• How long urinary symptoms lasted?
• Erections? Sexual history i.e stricture from past STIs.
• Any past medical history of UTIs, tumours, diabetes, stones, prostate issues.
• Any recent surgeries?
• Any regular medications?
• Agent, reaction, treatment.
• E.g. Fluvax, pneumococcal.
• Any family history of UTIs, tumours, diabetes, stones, prostate issues.
• Occupation i.e. heavy metal exposure.
• Living Arrangements i.e. family support, impact of chronic disease, dialysis.
• Alcohol/recreational drugs
• Physical activity
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform a physical examination on this patient.
1. Introduction, explanation, consent, wash hands.
2. General inspection: mental status, hyperventilation, uraemic fetor, pigmentation (brown tinge), skin nodules.
3. Vital signs:
• BP - hypertension, postural variation.
• BMI, fluid intake, output chart, urine analysis.
• Nails - leuconychia, Mees lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), half and half nails (CKD), palmar crease pallor, asterixis, scars, AV fistulae/shunts over wrist and forearm, bruising, pigmentation, scratch marks (due to hyperphosphataemia), vasculitic changes (causing renal disease like SLE, systemic sclerosis).
• Facies associated with SLE and systemic sclerosis, conjunctival pallor, jaundice, band keratopathy and fundus check for diabetic or hypertensive retinopathy.
• Mouth - ulcers, thrush, hydration, uraemic factor, gingival hyperplasia associated with transplant medication.
6. Neck: scars (parathyroidectomy), vas-cath for haemodialysis.
• Inspection - scars, presence of a peritoneal dialysis catheter, distension (polycystic kidneys, ascites due to nephrotic syndrome) and visible masses.
• Palpation - tenderness, renal masses, ballot kidneys, hepatomegaly or splenomegaly (due to cysts associated with polycystic kidneys), presence of an enlarged bladder, abdominal aorta for aneurysm.
• Percussion - shifting dullness, percuss for an enlarged bladder.
• Auscultation - for renal artery bruit and abdominal aorta.
8. Back: bony tenderness (osteomalacia, secondary hypertension, multiple myeloma), sacral oedema, scars, renal angle tenderness.
9. Legs: oedema, skin changes as in arms, gouty tophi.
• JVP, carotid bruit (indicate atherosclerosis) and look for signs of CCF and pulmonary oedema, pericarditis, pericardial effusion.
• Lungs - signs of infection due to immunosuppression from CKD or as a result of treatment.
11. CNS: peripheral neuropathy, myopathy, carpal tunnel syndrome.
12. Rectal exam needs to be performed for scrotal masses and oedema. Pelvic exam for enlarged prostate in males.
What is your provisional and differential diagnoses?
• Provisional diagnosis:
- Acute renal failure (nausea, fatigue, oedema, pallor).
- DM + UTI.
- Renal, prostate tumour.
- DM nephropathy.
- Diabetic autonomic neuropathy.