ELDER TIP As a person ages, his bladder muscles weaken, which may result in incomplete bladder emptying and chronic urine retention — factors that predispose the older person to bladder infections.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Whooping cough:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Whooping cough is usually transmitted by the direct inhalation of contaminated droplets from a patient in the acute stage; it may also be spread indirectly through soiled linen and other articles contaminated by respiratory secretions.
Whooping cough is endemic throughout the world, usually occurring in late winter and early spring. In about 50% of cases, it strikes unimmunized children younger than age 1, because the immunization series hasn’t been completed and the child has had contact with an adult harboring the organisms.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Dysuria:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Appendicitis
Occasionally, appendicitis causes dysuria that persists throughout voiding and is accompanied by bladder tenderness. Appendicitis is characterized by periumbilical abdominal pain that shifts to McBurney’s point, anorexia, nausea, vomiting, constipation, slight fever, abdominal rigidity and rebound tenderness, and tachycardia.
Bladder cancer
In this predominantly male disorder, dysuria throughout voiding is a late symptom associated with urinary frequency and urgency, nocturia, hematuria, and perineal, back, or flank pain.
Cultural Cue: Bladder cancer is twice as common in White males as in Blacks. It’s relatively uncommon in Asians, Hispanics, and Native Americans.
Cystitis
Dysuria throughout voiding is common in all types of cystitis, as are urinary frequency, nocturia, straining to void, and hematuria. Bacterial cystitis, the most common cause of dysuria in women, may also produce urinary urgency, perineal and lower back pain, suprapubic discomfort, fatigue and, possibly, a low-grade fever. In chronic interstitial cystitis, dysuria is accentuated at the end of voiding. In tubercular cystitis, symptoms may also include urinary urgency, flank pain, fatigue, and anorexia. In viral cystitis, severe dysuria occurs with gross hematuria, urinary urgency, and fever.
Gender Cue: Women are more prone to develop cystitis than men because they have a shorter urethra. For men, age is a factor: Older men have a 15% higher risk of developing cystitis.
Diverticulitis
Inflammation near the bladder may cause dysuria throughout voiding. Other effects include urinary frequency and urgency, nocturia, hematuria, fever, abdominal pain and tenderness, perineal pain, constipation or diarrhea and, possibly, an abdominal mass.
Paraurethral gland inflammation
Dysuria throughout voiding is accompanied by urinary frequency and urgency, diminished urine stream, mild perineal pain and, occasionally, hematuria in this disorder.
Prostatitis
Acute prostatitis commonly causes dysuria throughout or toward the end of voiding as well as a diminished urine stream, urinary frequency and urgency, hematuria, suprapubic fullness, fever, chills, fatigue, myalgia, nausea, vomiting, and constipation. In chronic prostatitis, urethral narrowing causes dysuria throughout voiding. Related effects are urinary frequency and urgency; diminished urine stream; perineal, back, and buttocks pain; urethral discharge; nocturia; and, at times, hematospermia and ejaculatory pain.
Pyelonephritis (acute)
More common in females than in males, this disorder causes dysuria throughout voiding. Other features include persistent high fever with chills, costovertebral angle tenderness, unilateral or bilateral flank pain, weakness, urinary urgency and frequency, nocturia, straining on urination, and hematuria. Nausea, vomiting, and anorexia may also occur.
Reiter’s syndrome
In this predominantly male disorder, dysuria occurs 1 to 2 weeks after sexual contact. Initially, the patient has a mucopurulent discharge, urinary urgency and frequency, meatal swelling and redness, suprapubic pain, anorexia, weight loss, and low-grade fever. Hematuria, conjunctivitis, arthritic symptoms, a papular rash, and oral and penile lesions may follow.
Urethral syndrome
Occurring in sexually active women, this syndrome mimics urethritis. Dysuria throughout voiding may occur with urinary frequency, diminished urine stream, suprapubic aching and cramping, tenesmus, and low back and unilateral flank pain. In the absence of pyuria, symptoms will usually resolve without intervention.
Urethritis
Primarily found in sexually active males, this infection causes dysuria throughout voiding. It’s accompanied by a reddened meatus and a copious, yellow, purulent discharge (gonorrheal infection) or a white or clear mucoid discharge (nongonorrheal infection).
Urinary obstruction
Outflow obstruction by urethral strictures or calculi produces dysuria throughout voiding. (In a complete obstruction, bladder distention develops and dysuria precedes voiding.) Other features are diminished urine stream, urinary frequency and urgency, and a sensation of fullness or bloating in the lower abdomen or groin.
Vaginitis
Characteristically, dysuria occurs throughout voiding as urine touches inflamed or ulcerated labia. Other findings include urinary frequency and urgency, nocturia, hematuria, perineal pain, and vaginal discharge and odor.
Other causes
Chemical irritants
Dysuria may result from irritating substances, such as bubble bath salts and feminine deodorants; it’s usually most intense at the end of voiding. Spermicides may cause dysuria in both sexes as well as urinary frequency and urgency, a diminished urine stream and, possibly, hematuria.
Drugs
Monoamine oxidase inhibitors and metyrosine can cause dysuria.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Oliguria:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Acute tubular necrosis (ATN)
An early sign of ATN, oliguria may occur abruptly (in shock) or gradually (in nephrotoxicity). Usually, it persists for about 2 weeks, followed by polyuria. Related features include signs of hyperkalemia (muscle weakness and cardiac arrhythmias); uremia (anorexia, confusion, lethargy, twitching, seizures, pruritus, and Kussmaul’s respirations); and heart failure (edema, jugular vein distention, crackles, and dyspnea).
Benign prostatic hyperplasia
This disorder, which is common in men older than age 50, in rare cases may cause oliguria resulting from bladder outlet obstruction. More common symptoms include urinary frequency or hesitancy, urge or overflow incontinence, decrease in the force of the urine stream or inability to stop the stream, nocturia and, possibly, hematuria.
Bladder neoplasm
Uncommonly, this disorder may produce oliguria if the tumor obstructs the bladder outlet. The cardinal signs of such obstruction include urinary frequency and urgency, as well as gross hematuria, which may lead to clot retention and flank pain.
Calculi
Oliguria or anuria may result from stones lodging in the kidneys, ureters, bladder outlet, or urethra. Associated signs and symptoms include urinary frequency and urgency, dysuria, and hematuria or pyuria. Usually, the patient experiences renal colic—excruciating pain that radiates from the CVA to the flank, the suprapubic region, and the external genitalia. This pain may be accompanied by nausea, vomiting, hypoactive bowel sounds, abdominal distention and, occasionally, fever and chills.
Cholera
In this bacterial infection, severe water and electrolyte loss lead to oliguria, thirst, weakness, muscle cramps, decreased skin turgor, tachycardia, hypotension, and abrupt watery diarrhea and vomiting. Death may occur in hours without treatment.
Cirrhosis
In severe cirrhosis, hepatorenal syndrome may develop with oliguria, in addition to ascites, edema, fatigue, weakness, jaundice, hypotension, tachycardia, gynecomastia, testicular atrophy, and signs of GI bleeding such as hematemesis.
Glomerulonephritis (acute)
This disorder produces oliguria or anuria. Other features are mild fever, fatigue, gross hematuria, proteinuria, generalized edema, elevated blood pressure, headache, nausea and vomiting, flank and abdominal pain, and signs of pulmonary congestion (dyspnea and productive cough).
Heart failure
Oliguria may occur in left ventricular failure as a result of low cardiac output and decreased renal perfusion. Accompanying signs and symptoms include dyspnea, fatigue, weakness, peripheral edema, distended jugular veins, tachycardia, tachypnea, crackles, and a dry or productive cough. In advanced heart failure, the patient may also develop orthopnea, cyanosis, clubbing, ventricular gallop, diastolic hypertension, cardiomegaly, and hemoptysis.
Hypovolemia
Any disorder that decreases circulating fluid volume can produce oliguria. Associated findings include orthostatic hypotension, apathy, lethargy, fatigue, gross muscle weakness, anorexia, nausea, profound thirst, dizziness, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Pyelonephritis (acute)
Accompanying the sudden onset of oliguria in this disorder are high fever with chills, fatigue, flank pain, CVA tenderness, weakness, nocturia, dysuria, hematuria, urinary frequency and urgency, and tenesmus. The urine may appear cloudy. Occasionally, the patient also experiences anorexia, nausea, diarrhea, and vomiting.
Renal artery occlusion (bilateral)
This disorder may produce oliguria or, more commonly, anuria. Other features include severe, constant upper abdominal and flank pain, nausea and vomiting, and hypoactive bowel sounds. The patient also develops a fever 1 to 2 days after the occlusion, as well as diastolic hypertension.
Renal failure (chronic)
Oliguria is a major sign of end-stage chronic renal failure. Associated findings reflect progressive uremia and include fatigue, weakness, irritability, uremic fetor, ecchymoses and petechiae, peripheral edema, elevated blood pressure, confusion, emotional lability, drowsiness, coarse muscle twitching, muscle cramps, peripheral neuropathies, anorexia, metallic taste in the mouth, nausea and vomiting, constipation or diarrhea, stomatitis, pruritus, pallor, and yellow- or bronze-tinged skin. Eventually, seizures, coma, and uremic frost may develop.
Renal vein occlusion (bilateral)
This disorder occasionally causes oliguria accompanied by acute low back and flank pain, CVA tenderness, fever, pallor, hematuria, enlarged and palpable kidneys, edema and, possibly, signs of uremia.
Retroperitoneal fibrosis
Oliguria may result from bilateral ureteral obstruction by dense fibrous tissue. Other effects include hematuria, diffuse low back pain, anorexia, weight loss, nausea and vomiting, fatigue, malaise, low-grade fever, and elevated blood pressure.
Sepsis
Any condition that results in sepsis may produce oliguria, along with fever, chills, restlessness, confusion, diaphoresis, anorexia, vomiting, diarrhea, pallor, hypotension, and tachycardia. The patient may exhibit signs of local infection, such as dysuria and wound drainage. In severe infection, he may develop lactic acidosis marked by Kussmaul’s respirations.
Toxemia of pregnancy
In severe preeclampsia, oliguria may be accompanied by elevated blood pressure, dizziness, diplopia, blurred vision, epigastric pain, nausea and vomiting, irritability, and severe frontal headache. Typically, the oliguria is preceded by generalized edema and sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester, or more than 1 lb (0.5 kg) per week during the third trimester. If preeclampsia progresses to eclampsia, the patient develops seizures and may slip into coma.
Urethral stricture
This disorder produces oliguria accompanied by chronic urethral discharge, urinary frequency and urgency, dysuria, pyuria, and diminished urine stream. As obstruction worsens, urine extravasation may lead to formation of urinomas and urosepsis.
Other causes
Diagnostic studies
Radiographic studies that use contrast media may cause nephrotoxicity and oliguria.
Drugs
Oliguria may result from drugs that cause decreased renal perfusion (diuretics), nephrotoxicity (most notably, aminoglycosides and chemotherapeutic drugs), urine retention (adrenergics and anticholinergics), or urinary obstruction associated with precipitation of urinary crystals (sulfonamides and acyclovir).
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Polyuria:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Acute tubular necrosis
During the diuretic phase of this disorder, polyuria of less than 8 L/day gradually subsides after 8 to 10 days. Urine specific gravity (1.010 or less) increases as polyuria subsides. Related findings include weight loss, decreasing edema, and nocturia.
Diabetes insipidus
Polyuria of about 5 L/day with a specific gravity of 1.005 or less is common, although extreme polyuria—up to 30 L/day—occasionally occurs. Polyuria is commonly accompanied by polydipsia, nocturia, fatigue, and signs of dehydration, such as poor skin turgor and dry mucous membranes.
Diabetes mellitus
With this disorder, polyuria seldom exceeds 5 L/day, and urine specific gravity typically exceeds 1.020. The patient usually reports polydipsia, polyphagia, weight loss, weakness, frequent urinary tract infections and yeast vaginitis, fatigue, and nocturia. The patient may also display signs of dehydration and anorexia.
Glomerulonephritis (chronic)
Polyuria gradually progresses to oliguria with this disorder. Urine output is usually less than 4 L/day; specific gravity is about 1.010. Related GI findings include anorexia, nausea, and vomiting. The patient may experience drowsiness, fatigue, edema, headache, elevated blood pressure, and dyspnea. Nocturia, hematuria, frothy or malodorous urine, and mild to severe proteinuria may occur.
Hypercalcemia
Elevated plasma calcium levels may lead to nephropathy, usually producing polyuria of less than 5 L/day with a specific gravity of about 1.010. Accompanying signs and symptoms include polydipsia, nocturia, constipation, paresthesia and, occasionally, hematuria, and pyuria. With severe hypercalcemia, the patient’s condition worsens rapidly and he experiences anorexia, vomiting, stupor progressing to coma, and renal failure.
Hypokalemia
Prolonged potassium depletion may lead to nephropathy, which results in polyuria—usually less than 5 L/day with a specific gravity of about 1.010. Associated findings include polydipsia, circumoral and foot paresthesia, hypoactive deep tendon reflexes, fatigue, hypoactive bowel sounds, nocturia, arrhythmias, and muscle cramping, weakness, or paralysis.
Postobstructive uropathy
After resolution of a urinary tract obstruction, polyuria—usually more than 5 L/day with a specific gravity of less than 1.010—occurs for up to several days before gradually subsiding. Bladder distention and edema may occur with nocturia and weight loss. Occasionally, signs of dehydration appear.
Psychogenic polydipsia
Most common in those older than age 30, this disorder usually produces dilute polyuria of 3 to 15 L/day, depending on fluid intake. The patient may appear depressed and have a headache and blurred vision. Weight gain, edema, elevated blood pressure and, occasionally, stupor or coma may develop. With severe overhydration, signs of heart failure may present.
Pyelonephritis
Acute pyelonephritis usually results in polyuria of less than 5 L/day with a low but variable specific gravity. Other findings include persistent high fever, flank pain (usually unilateral), hematuria, costovertebral angle tenderness, chills, weakness, dysuria, urinary frequency and urgency, tenesmus, and nocturia. Occasionally, nausea, anorexia, vomiting, and hypoactive bowel sounds occur.
Chronic pyelonephritis produces polyuria of less than 5 L/day that declines as renal function worsens. Urine specific gravity is usually about 1.010 but may be higher if proteinuria is present. Other effects include irritability, paresthesia, fatigue, nausea, vomiting, diarrhea, drowsiness, anorexia, pyuria and, in late stages, elevated blood pressure.
Sheehan’s syndrome
This syndrome of postpartum pituitary necrosis may cause polyuria of over 5 L/day with a specific gravity of 1.001 to 1.005. Associated findings include polydipsia, nocturia, and fatigue. Reproductive effects include failure to lactate, amenorrhea, decreased pubic and axillary hair growth, and reduced libido.
Sickle cell anemia
This disorder may cause nephropathy, typically producing polyuria of less than 5 L/day with a specific gravity of about 1.020. Additional findings include polydipsia, fatigue, abdominal cramps, arthralgia, priapism and, occasionally, leg ulcers, and bony deformities.
Other causes
Diagnostic tests
Transient polyuria can result from radiographic tests that use contrast media.
Drugs
Diuretics characteristically produce polyuria. Cardiotonics, vitamin D, demeclocycline, phenytoin, lithium, and propoxyphene can also produce polyuria.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary frequency:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Anxiety neurosis
Morbid anxiety produces urinary frequency and other types of genitourinary dysfunction, such as dysuria, impotence, and frigidity. Other findings may include headache, diaphoresis, hyperventilation, palpitations, muscle spasm, generalized motor weakness, dizziness, polyphagia, and constipation or other GI complaints.
Benign prostatic hyperplasia
Prostatic enlargement causes urinary frequency along with nocturia and possibly incontinence and hematuria. Initial effects are those of prostatism: reduced caliber and force of the urine stream, urinary hesitancy and tenesmus, inability to stop the urine stream, a feeling of incomplete voiding, and occasionally urine retention. Assessment reveals bladder distention.
Bladder calculus
Bladder irritation from a calculus may lead to urinary frequency and urgency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. If the calculus lodges in the bladder neck, the patient may have overflow incontinence and referred pain to the lower back or heel.
Bladder cancer
Urinary frequency, urgency, dribbling, and nocturia may develop from bladder irritation. The first sign of bladder cancer commonly is intermittent gross, painless hematuria (often with clots). Patients with invasive lesions commonly have suprapubic or pelvic pain from bladder spasms.
Multiple sclerosis (MS)
Urinary frequency, urgency, and incontinence are common urologic findings in patients with MS, but these effects widely vary and tend to wax and wane. Visual problems (such as diplopia and blurred vision) and sensory impairment (such as paresthesia) are usually the earliest symptoms. Other findings may include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer
In advanced prostate cancer, urinary frequency may occur along with hesitancy, dribbling, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped prostate.
Prostatitis
Acute prostatitis commonly produces urinary frequency and urgency, dysuria, nocturia, and a purulent urethral discharge. Other findings include fever, chills, low back pain, myalgia, arthralgia, and perineal fullness. The prostate may be tense, boggy, tender, and warm. Prostate massage to obtain prostatic fluid is contraindicated. Signs and symptoms of chronic prostatitis are usually the same as those of the acute form, but to a lesser degree. The patient may also experience pain on ejaculation.
Rectal tumor
The pressure that this tumor exerts on the bladder may cause urinary frequency. Early findings include altered bowel elimination habits, commonly starting with an urgent need to defecate on arising or obstipation alternating with diarrhea; blood or mucus in the stool; and a sense of incomplete evacuation.
Reiter’s syndrome
In this self-limiting syndrome, urinary frequency and other symptoms of acute urethritis occur 1 to 2 weeks after sexual contact. Other symptoms of Reiter’s syndrome include asymmetrical arthritis of the knees, ankles, and metatarsophalangeal joints; unilateral or bilateral conjunctivitis; and small painless ulcers on the mouth, tongue, glans penis, palms, and soles.
Reproductive tract tumor
A tumor in the female reproductive tract may compress the bladder, causing urinary frequency. Other findings vary but may include abdominal distention, menstrual disturbances, vaginal bleeding, weight loss, pelvic pain, and fatigue.
Spinal cord lesion
Incomplete cord transection results in urinary frequency, continuous overflow, dribbling, urgency when voluntary control of sphincter function weakens, urinary hesitancy, and bladder distention. Other effects occur below the level of the lesion and include weakness, paralysis, sensory disturbances, hyperreflexia, and impotence.
Urethral stricture
Bladder decompensation produces urinary frequency, urgency, and nocturia. Early signs include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence, urinoma, and urosepsis may develop.
UTI
Affecting the urethra, the bladder, or the kidneys, this common cause of urinary frequency may also produce urgency, dysuria, hematuria, cloudy urine and, in males, a urethral discharge. The patient may report a fever and bladder spasms or a feeling of warmth during urination. Women may experience suprapubic or pelvic pain. In young adult males, a UTI is usually related to sexual contact.
Other causes
Diuretics
These substances, which include caffeine, reduce the body’s total volume of water and salt by increasing urine excretion. Excessive intake of coffee, tea, and other caffeinated beverages leads to urinary frequency.
Treatments
Radiation therapy may cause bladder inflammation, leading to urinary frequency.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary hesitancy:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Benign prostatic hyperplasia
Signs and symptoms of this disorder depend on the extent of prostatic enlargement and the lobes affected. Characteristic early findings include urinary hesitancy, reduced caliber and force of the urine stream, perineal pain, a feeling of incomplete voiding, inability to stop the urine stream, and occasionally urine retention. As the obstruction increases, the patient may develop urinary frequency, nocturia, urinary overflow, incontinence, bladder distention and, possibly, hematuria.
Prostate cancer
In advanced cancer, urinary hesitancy may occur along with frequency, dribbling, nocturia, dysuria, bladder distention, perineal pain, and constipation. Digital rectal examination commonly reveals a hard, nodular prostate.
Spinal cord lesion
A lesion below the micturition center that has destroyed the sacral nerve roots causes urinary hesitancy, tenesmus, and constant dribbling from urine retention and overflow incontinence. Associated findings are urinary frequency and urgency, dysuria, and nocturia.
Urethral stricture
Partial obstruction of the lower urinary tract secondary to trauma or infection produces urinary hesitancy, tenesmus, and decreased force and caliber of the urine stream. Urinary frequency and urgency, nocturia, and eventually overflow incontinence may develop. Pyuria usually indicates accompanying infection. Increased obstruction may lead to urine extravasation and formation of urinomas.
UTI
Urinary hesitancy may be associated with UTIs. Characteristic urinary changes include frequency, dysuria, nocturia, cloudy urine and, possibly, hematuria. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, pelvic, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Drugs
Anticholinergics and drugs with anticholinergic properties (such as tricyclic antidepressants and some nasal decongestants and cold remedies) may cause urinary hesitancy. Hesitancy also may occur in patients recovering from general anesthesia.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary incontinence:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Benign prostatic hyperplasia (BPH)
Overflow incontinence is common in this disorder as a result of urethral obstruction and urine retention. BPH begins with a group of signs and symptoms known as prostatism: reduced caliber and force of the urine stream, urinary hesitancy, and a feeling of incomplete voiding. As the obstruction increases, the patient may develop urinary frequency, nocturia and, possibly, hematuria. Examination reveals bladder distention and an enlarged prostate.
Bladder calculus
Overflow incontinence may occur if the calculus lodges in the bladder neck. Associated findings vary but may include those of an irritable bladder: urinary frequency and urgency, dysuria, hematuria, and suprapubic pain from bladder spasms. Pelvic pain may be referred to the tip of the penis, vulva, low back, or heel and may be exacerbated by movement.
Bladder cancer
Urge incontinence and hematuria are common findings in bladder cancer; obstruction by a tumor may produce overflow incontinence. The early stages can be asymptomatic. Other urinary signs and symptoms include frequency, dysuria, nocturia, dribbling, and suprapubic pain from bladder spasms after voiding. A mass may be palpable on bimanual examination.
Diabetic neuropathy
Autonomic neuropathy may cause painless bladder distention with overflow incontinence. Related findings include episodic constipation or diarrhea (which is commonly nocturnal), impotence and retrograde ejaculation, orthostatic hypotension, syncope, and dysphagia.
Guillain-Barré syndrome
Urinary incontinence may occur early in this disorder as a result of peripheral and autonomic nerve dysfunction. The cardinal sign is progressive, profound muscle weakness, which typically starts in the legs and extends to the arms and facial nerves within 24 to 72 hours. Associated findings include paresthesia, dysarthria, nasal speech, dysphagia, orthostatic hypotension, tachycardia, fecal incontinence, diaphoresis, drooling, and pain in the shoulders, thighs, or lumbar region.
Multiple sclerosis (MS)
Urinary incontinence, urgency, and frequency are common urologic findings in MS. Visual problems and sensory impairment are usually the first symptoms. Other findings include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer
Urinary incontinence usually occurs only in the advanced stages of prostate cancer. Urinary frequency and hesitancy, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped, nodular prostate are other common late findings.
Prostatitis (chronic)
Urinary incontinence may occur as a result of urethral obstruction from an enlarged prostate. Other findings include urinary frequency and urgency, dysuria, hematuria, bladder distention, a persistent urethral discharge, dull perineal pain that may radiate to other areas, ejaculatory pain, and decreased libido.
Spinal cord injury
Complete cord transection above the sacral level causes flaccid paralysis of the bladder. Overflow incontinence follows rapid bladder distention. Other findings include paraplegia, sexual dysfunction, sensory loss, muscle atrophy, anhidrosis, and loss of reflexes distal to the injury.
Stroke
Urinary incontinence may be transient or permanent in a stroke patient. Associated findings reflect the site and extent of the lesion and may include impaired mentation, emotional lability, behavioral changes, altered level of consciousness, and seizures. Sensorimotor effects may include contralateral hemiplegia, dysarthria, dysphagia, ataxia, apraxia, agnosia, aphasia, and unilateral sensory loss. Headache, vomiting, visual deficits, and decreased visual acuity may also occur.
Urethral stricture
Partial obstruction of the lower urinary tract due to trauma or infection produces urinary hesitancy, tenesmus, and decreased force and caliber of the urine stream. Urinary frequency and urgency, nocturia, and eventually overflow incontinence may also occur. As the obstruction increases, urine extravasation may lead to formation of urinomas and urosepsis.
UTI
Besides incontinence, a UTI may produce urinary urgency, dysuria, hematuria, cloudy urine and, in males, a urethral discharge. Bladder spasms or a feeling of warmth during urination may occur.
Other causes
Surgery
Urinary incontinence may occur after prostatectomy as a result of urethral sphincter damage.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urinary urgency:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Amyotrophic lateral sclerosis (ALS)
ALS occasionally produces urinary urgency. More common findings include muscle weakness, cramping, atrophy, and coarse fasciculations in the forearms and hands. Brain stem involvement causes difficulty speaking, chewing, swallowing, and breathing. Cognitive function is usually unaffected.
Bladder calculus
Bladder irritation can lead to urinary urgency and frequency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. Pain may be referred to the penis, vulva, lower back, or heel.
Multiple sclerosis (MS)
Urinary urgency, frequency, and incontinence are common urologic findings in MS. Like other symptoms of MS, these effects may wax and wane. Visual and sensory impairments are usually the earliest findings. Others include constipation, muscle weakness, paralysis, spasticity, intention tremor, hyperreflexia, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability.
Reiter’s syndrome
In this self-limiting syndrome that primarily affects males, urinary urgency and other symptoms of acute urethritis occur 1 to 2 weeks after sexual contact. Other symptoms include asymmetrical arthritis of the knees, ankles, or metatarsal phalangeal joints; conjunctivitis in one or both eyes; and ulcers on the penis, mouth, tongue, palms, or soles.
Spinal cord lesion
Urinary urgency can result from incomplete cord transection when voluntary control of sphincter function weakens. Urinary frequency, difficulty initiating and inhibiting a urine stream, and bladder distention and discomfort may also occur. Neuromuscular effects distal to the lesion include weakness, paralysis, hyperreflexia, sensory disturbances, and impotence.
Urethral stricture
Bladder decompensation produces urinary urgency, frequency, and nocturia. Early signs and symptoms include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence may occur.
UTI
Urinary urgency is commonly associated with UTIs. Other characteristic urinary changes include frequency, hematuria, dysuria, nocturia, cloudy urine, and sometimes urinary hesitancy. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Treatments
Radiation therapy may irritate and inflame the bladder, causing urinary urgency.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urine cloudiness:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
UTI
Cloudy urine is common in UTIs. Other urinary findings include urgency, frequency, hesitancy, hematuria, dysuria, nocturia and, in males, a urethral discharge. Other effects include fever, chills, malaise, nausea and vomiting, bladder spasms, costovertebral angle tenderness, and suprapubic, low back, or flank pain.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Cough, barking:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Aspiration of foreign body
Partial obstruction of the upper airway first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing, and possibly cyanosis.
Epiglottiditis
This life-threatening disorder has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.
Laryngotracheobronchitis (acute)
Also known as viral croup, this infection is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.
As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.
Spasmodic croup
Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Cough, nonproductive:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Airway occlusion
Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient exhibits gagging, wheezing, hoarseness, stridor, tachycardia, and decreased breath sounds.
Anthrax (inhalation)
This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.
Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.
Aortic aneurysm (thoracic)
This disorder causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor, and possibly paresthesia or neuralgia.
Asthma
Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing and progressing to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.
Atelectasis
As lung tissue deflates in atelectasis, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, tachycardia, decreased breath sounds, cyanotic skin, and diaphoresis. His chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.
Avian influenza
These potentially life-threatening viruses are spread to humans through infected poultry and surfaces contaminated with infected bird excretions. Infected individuals may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia. To date this strain of the virus has not surfaced in the United States; however, a recent outbreak in Asian and European countries has caused worldwide concern that the virus may spread through both infected humans and birds. Treatment with two of the four FDA-approved antiviral medications has proven effective with some virus strains, and an experimental vaccine is currently under investigation.
Bronchitis (chronic)
This disorder starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.
Bronchogenic carcinoma
The earliest indicators of this disease can be a chronic nonproductive cough, dyspnea, and vague chest pain. The patient may also be wheezing.
Common cold
Most colds start with a nonproductive, hacking cough and progress to some mix of sneezing, rhinorrhea, nasal congestion, sore throat, headache, malaise, fatigue, myalgia, and arthralgia.
Esophageal achalasia
In this disorder, regurgitation and aspiration produce a dry cough and, possibly, recurrent pulmonary infections and dysphagia.
Esophageal diverticula
The patient with this disorder has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.
Esophageal occlusion
This disorder is marked by sudden nonproductive coughing and gagging with a sensation of something stuck in the throat. Other findings include neck or chest pain and dysphagia.
Esophagitis with reflux
This disorder commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may also experience chest pain that mimics angina pectoris, heartburn that worsens if he lies down after eating, increased salivation, dysphagia, hematemesis, and melena.
Hantavirus Pulmonary Syndrome A nonproductive cough is common in patients with this disorder, which is marked by noncardiogenic pulmonary edema. Other findings include headache, myalgia, fever, nausea, and vomiting.
Hodgkin’s disease
This disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.
Hypersensitivity pneumonitis
In this disorder, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen.
Interstitial lung disease
A patient with this disorder has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.
Laryngeal tumor
A mild nonproductive cough, minor throat discomfort, and hoarseness are early signs of this disorder. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.
Laryngitis
Acute laryngitis causes a nonproductive cough with localized pain (especially when the patient swallows or speaks) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.
Legionnaires’ disease
After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, nonpurulent and, possibly, blood-tinged sputum.
Lung abscess
This disorder typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, blood-tinged sputum.
Mediastinal tumor
A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, jugular vein distention, and facial or neck edema.
Pericardial effusion
The most common signs and symptoms of this disorder are dysphagia, fever, pleuritic chest pain, and pericardial friction rub. A severe nonproductive cough occurs rarely.
Pleural effusion
A nonproductive cough, dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.
Pneumonia
Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.
In mycoplasmal pneumonia, a nonproductive cough develops 2 to 3 days after the onset of malaise, headache, and sore throat. The cough may be paroxysmal, causing substernal chest pain. The patient commonly has a fever but doesn’t appear seriously ill.
Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.
Pneumothorax
This life-threatening disorder causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.
Psittacosis
In this disorder, an initially dry, hacking cough later produces small amounts of blood-streaked, mucoid sputum. Psittacosis may begin abruptly with chills, fever, headache, myalgia, and prostration. The patient may also have tachypnea, fine crackles, epistaxis and, rarely, chest pain.
Pulmonary edema
This disorder initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and a cough that produces frothy, blood-streaked sputum.
Pulmonary embolism
A life-threatening pulmonary embolism may suddenly produce a dry cough, dyspnea, and pleuritic or anginal chest pain. In most cases, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.
Sarcoidosis
In this disorder, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.
Severe acute respiratory syndrome (SARS)
SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.
Sinusitis (chronic)
This disorder can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.
Tracheobronchitis (acute)
Initially, this disorder produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezing are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm, severe wheezing, and increased coughing.
Tularemia
Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Diagnostic tests
Pulmonary function tests and bronchoscopy may stimulate cough receptors and trigger coughing.
Drugs
Certain drugs, such as angiotensin-converting enzyme inhibitors, may also cause a nonproductive cough.
Treatments
Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Cough, productive:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Actinomycosis
This disorder begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.
Aspiration pneumonitis
This disorder causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis.
Asthma (acute)
A severe asthma attack, which can be life-threatening, may produce tenacious mucoid sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expiration, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.
Bronchiectasis
The chronic cough of this disorder produces copious mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.
Bronchitis (chronic)
The cough associated with chronic bronchitis may be nonproductive initially; eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood tinged and foul smelling. The cough, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.
The patient also exhibits prolonged expiration, accessory muscle use, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.
Chemical pneumonitis
This disorder causes a cough with purulent sputum. It may also cause dyspnea, wheezing, orthopnea, fever, malaise, crackles, laryngitis, rhinitis, and mucous membrane irritation of the conjunctivae, throat, and nose. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; in severe pneumonitis, however, they may recur 2 to 5 weeks later.
Common cold
The common cold may cause a productive cough with mucoid or mucopurulent sputum, but it usually starts with a dry, hacking cough, sore throat, sneezing, rhinorrhea, and nasal congestion. Headache, malaise, fatigue, myalgia, and arthralgia may also occur.
Emphysema
This disorder causes a chronic productive cough with scant mucoid, translucent, grayish white sputum that can become mucopurulent. Patients with emphysema are typically thin and have the characteristic pink or red complexion (“pink puffer” appearance). They may also exhibit increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, anorexia, and weight loss. Clubbing is a late sign.
Legionnaires’ disease
This disorder causes a cough that produces scant mucoid, nonpurulent and, possibly, blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia, and possibly diarrhea. Within 12 to 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.
Lung abscess (ruptured)
The cardinal sign of a ruptured lung abscess is a cough that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.
Lung cancer
One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms of lung cancer include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.
Nocardiosis
This disorder causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, weight loss, malaise, fatigue, and diminished or absent breath sounds. The patient’s chest is dull on percussion.
North American blastomycosis
This chronic disorder may produce a dry hacking cough or a productive cough with bloody or purulent sputum. Other findings include pleuritic chest pain, fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.
Plague
Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pneumonia
Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.
Mycoplasmal pneumonia may cause a cough that produces scant blood-flecked sputum. In most cases, however, a nonproductive cough starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.
Psittacosis
As this disorder progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly with chills, fever, headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe psittacosis may produce stupor, delirium, and coma.
Pulmonary coccidioidomycosis
This disorder causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic chest pain, sore throat, headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.
Pulmonary edema
When severe, this life-threatening disorder causes a cough that produces frothy, blood-tinged sputum. Early signs and symptoms include exertional dyspnea, paroxysmal nocturnal dyspnea followed by orthopnea, and a cough that may be nonproductive initially. Fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop may also occur. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and the productive cough, worsening tachycardia, and possibly arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.
Pulmonary embolism
This life-threatening disorder causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, in a large embolus, cyanosis, syncope, and distended jugular veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.
Pulmonary tuberculosis
This disorder causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may exhibit chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.
Silicosis
A productive cough with mucopurulent sputum is the earliest sign of this disorder. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.
Tracheobronchitis
Inflammation initially causes a nonproductive cough followed by chills, sore throat, slight fever, muscle and back pain, and substernal tightness. As secretions increase, the cough produces mucoid, mucopurulent, or purulent sputum. The patient typically has rhonchi and wheezing; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.
Other causes
Diagnostic tests
Bronchoscopy and pulmonary function tests may increase productive coughing.
Drugs
Expectorants, such as ammonium chloride, guaifenesin, potassium iodide, and terpin hydrate, increase productive coughing.
Respiratory therapy
Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Lower urinary tract infection
❑ Acute pyelonephritis
❑ Urethritis
❑ Vaginitis
❑ Acute prostatitis
❑ Urethral calculus
❑ Reiter syndrome
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Source: Field Guide to Bedside Diagnosis, 2007
Polyuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Urinary tract infection
❑ Diabetes mellitus
❑ Diuretic therapy
❑ Bladder outlet obstruction
❑ Nephrogenic diabetes insipidus
❑ Central diabetes insipidus
❑ Primary polydipsia
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Source: Field Guide to Bedside Diagnosis, 2007
Proteinuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Diabetes
❑ Drugs/toxins
❑ Acute tubular necrosis
❑ Glomerulonephritis
❑ Orthostatic
❑ Systemic lupus erythematosus
❑ Toxemia
❑ Polycystic kidneys
❑ Interstitial nephritis
❑ Renal vein thrombosis
❑ Multiple myeloma
❑ Amyloidosis
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary Incontinence:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Cystitis
❑ Benign prostatic hypertrophy
❑ Pelvic floor relaxation
❑ Drugs
❑ Prostatitis
❑ Diabetes
❑ Cough
❑ Multiple sclerosis
❑ Spinal cord compression
❑ Decreased cortical inhibition
❑ Vesicovaginal fistula
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Source: Field Guide to Bedside Diagnosis, 2007
Anuria/Oliguria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Acute tubular necrosis
❑ Prerenal azotemia
❑ Tubular toxins
❑ Bladder outlet obstruction
❑ Bilateral renal artery occlusion
❑ Nephrosclerosis
❑ Acute glomerulonephritis
❑ Interstitial nephritis
❑ Renal artery thrombosis
❑ Renal vein thrombosis
❑ Ureteral calculus with a solitary kidney
❑ Pelvic tumor
❑ Retroperitoneal fibrosis
❑ Infiltrative renal disease
❑ Vasculitis
❑ Rhabdomyolysis
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Source: Field Guide to Bedside Diagnosis, 2007
Acute Cough:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Viral upper respiratory infection
❑ Asthma
❑ Sinusitis
❑ Mycoplasma bronchitis
❑ Pneumonia
❑ Gastroesophageal reflux
❑ Congestive heart failure
❑ ACE inhibitor
❑ Aspiration
❑ Cough in HIV
❑ Thermal
❑ Fume inhalation
❑ Pertussis
❑ Lung abscess
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Source: Field Guide to Bedside Diagnosis, 2007
Chronic Cough:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Upper respiratory infection
❑ Allergy
❑ Asthma
❑ Chronic bronchitis
❑ Chronic sinusitis
❑ Gastroesophageal reflux
❑ ACE inhibitor
❑ Pollutants
❑ Psychogenic
❑ Foreign body
❑ Congestive heart failure
❑ Lung cancer
❑ Tuberculosis
❑ Mediastinal mass
❑ Bronchiectasis
❑ Pulmonary fibrosis
❑ Cystic fibrosis
❑ Aspergillosis
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Source: Field Guide to Bedside Diagnosis, 2007
Urinary tract infection, lower:
Causes
(Handbook of Diseases)
Most lower UTIs result from ascending infection by a single gram-negative enteric bacterium, such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, or Serratia. However, in a patient with neurogenic bladder, an indwelling urinary catheter, or a fistula between the intestine and bladder, lower UTI may result from simultaneous infection with multiple pathogens.
Infection may result from a breakdown in local defense mechanisms in the bladder that allow bacteria to invade the bladder mucosa and multiply. These bacteria cannot be readily eliminated by normal micturition.
The risk of cystitis is higher when the bladder or urethra becomes blocked and urine flow stops. It can occur when instruments are inserted into the urinary tract during procedures such as catheterization or cystoscopy. Other risks include pregnancy, diabetes, and a history of analgesic or reflux nephropathy. The elderly are at increased risk for developing UTIs due to incomplete emptying of the bladder; this is associated with conditions such as benign prostatic hyperplasia (BPH), prostatitis, and urethral strictures. Also, lack of adequate fluids, bowel incontinence, immobility or decreased mobility, indwelling urinary catheters, and placement in a nursing home all place the person at risk for developing an infection.
Bacterial flare-up
During treatment, bacterial flare-up is generally caused by the pathogenic organism’s resistance to the prescribed antimicrobial therapy. The presence of even a small number (less than 10,000/ml) of bacteria in a midstream urine sample obtained during treatment casts doubt on the treatment’s effectiveness.
Recurrent UTI
In 99% of patients, recurrent lower UTI results from reinfection by the same organism or from some new pathogen; in the remaining 1%, recurrence reflects persistent infection, usually from renal calculi, chronic bacterial prostatitis, or a structural anomaly that may become a source of infection.
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Source: Handbook of Diseases, 2003
Cough, barking:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.
Epiglottiditis.
Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.
Also known as viral croup, laryngotracheobronchitis is most common in children between ages 9 and 18 months and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, barking cough, hoarseness, and inspiratory stridor occur.
As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.
Spasmodic croup.
Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Cough, productive:
Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Actinomycosis begins with a cough that produces purulent sputum. Fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.
Aspiration pneumonitis causes coughing that produces pink, frothy, and possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, tachycardia, wheezing, and cyanosis.
A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, and then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.
The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.
Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.
The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.
Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, and then resolve; if severe, however, they may recur 2 to 5 weeks later.
Common cold.
When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications of the common cold include a dry, hacking cough, sneezing, headache, malaise, fatigue, rhinorrhea (watery to tenacious mucopurulent secretions), nasal congestion, sore throat, myalgia, and arthralgia.
Legionnaires’ disease causes a cough that produces scant mucoid, nonpurulent, and possibly blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly, diarrhea. Then, within 48 hours, the patient develops a dry cough and sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.
The cardinal sign of ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, and possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.
One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.
Nocardiosis.
Nocardiosis causes a productive cough with purulent, thick, tenacious, and possibly blood-tinged sputum and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient’s chest is dull on percussion.
North American blastomycosis.
With North American blastomycosis — a chronic disorder — coughing is dry and hacking, or produces bloody or purulent sputum. Other findings include pleuritic chest pain, fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.
Plague is an acute bacterial infection caused by Yersinia pestis. It’s one of the most virulent infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man when bitten by infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pneumonia.
Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.
Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Most common, however, is a nonproductive cough that starts 2 to 3 days after the onset of malaise, headache, fever, and sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles but generally don’t appear seriously ill.
Psittacosis.
As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, fever, headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.
Pulmonary coccidioidomycosis.
Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic chest pain, sore throat, headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.
When severe, pulmonary edema — a life-threatening disorder — causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea as well as paroxysmal nocturnal dyspnea, followed by orthopnea. Coughing may be nonproductive initially. Other signs and symptoms include fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and productive cough, worsening tachycardia and, possibly, arrhythmias. The patient’s skin becomes cold, clammy, and cyanotic, his blood pressure falls, and his pulse becomes thready.
Pulmonary embolism.
Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.
Pulmonary emphysema.
Pulmonary emphysema causes a chronic productive cough with scant, mucoid, translucent, grayish white sputum that can become mucopurulent. The patient is thin and has the characteristic “pink puffer” appearance with weight loss, increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, and anorexia. Clubbing is a late sign.
Pulmonary tuberculosis.
Pulmonary tuberculosis causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.
Silicosis.
A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.
Inflammation initially causes a nonproductive cough that later — following the onset of chills, sore throat, slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.
Other causes
Bronchoscopy and pulmonary function tests may increase productive coughing.
Drugs.
Expectorants, of course, increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.
Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Dysuria:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Appendicitis
Occasionally, appendicitis causes dysuria that persists throughout voiding and is accompanied by bladder tenderness. Appendicitis is characterized by periumbilical abdominal pain that shifts to McBurney’s point, anorexia, nausea, vomiting, constipation, slight fever, abdominal rigidity and rebound tenderness, and tachycardia.
Bladder cancer
In bladder cancer, a predominantly male disorder, dysuria throughout voiding is a late symptom associated with urinary frequency and urgency, nocturia, hematuria, and perineal, back, or flank pain.
CULTURAL CUE:Bladder cancer is twice as common in White males as in Black males. It’s relatively uncommon in Asians, Hispanics, and Native Americans.
Cystitis
Dysuria throughout voiding is common in all types of cystitis, as are urinary frequency, nocturia, straining to void, and hematuria. Bacterial cystitis, the most common cause of dysuria in women, may also produce urinary urgency, perineal and lower back pain, suprapubic discomfort, fatigue and, possibly, low-grade fever. With chronic interstitial cystitis, dysuria is accentuated at the end of voiding. In tubercular cystitis, symptoms may also include urinary urgency, flank pain, fatigue, and anorexia. With viral cystitis, severe dysuria occurs with gross hematuria, urinary urgency, and fever.
Diverticulitis
Inflammation near the bladder may cause dysuria throughout voiding. Other effects include urinary frequency and urgency, nocturia, hematuria, fever, abdominal pain and tenderness, perineal pain, constipation or diarrhea and, possibly, an abdominal mass.
Paraurethral gland inflammation
Dysuria throughout voiding occurs with urinary frequency and urgency, diminished urine stream, mild perineal pain and, occasionally, hematuria.
Prostatitis
Acute prostatitis commonly causes dysuria throughout or toward the end of voiding. Dysuria may be accompanied by a diminished urine stream, urinary frequency and urgency, hematuria, suprapubic fullness, fever, chills, fatigue, myalgia, nausea, vomiting, and constipation.
With chronic prostatitis, urethral narrowing causes dysuria throughout voiding. Related effects include urinary frequency and urgency; diminished urine stream; perineal, back, and buttocks pain; urethral discharge; nocturia; and, at times, hematospermia and ejaculatory pain.
Pyelonephritis (acute)
More common in females, acute pyelonephritis causes dysuria throughout voiding. Other features include persistent high fever with chills, costovertebral angle tenderness, unilateral or bilateral flank pain, weakness, urinary urgency and frequency, nocturia, straining on urination, and hematuria. Nausea, vomiting, and anorexia may also occur.
Reiter’s syndrome
With Reiter’s syndrome, a predominantly male disorder, dysuria occurs 1 to 2 weeks after sexual contact. Initially, the patient has a mucopurulent discharge, urinary urgency and frequency, meatal swelling and redness, suprapubic pain, anorexia, weight loss, and low-grade fever. Hematuria, conjunctivitis, arthritic symptoms, a papular rash, and oral and penile lesions may follow.
Urethral syndrome
Occurring in sexually active women, urethral syndrome mimics urethritis. Dysuria throughout voiding may occur with urinary frequency, diminished urine stream, suprapubic aching and cramping, tenesmus, and lower back and unilateral flank pain. In the absence of pyuria, symptoms usually resolve without intervention.
Urethritis
Primarily found in sexually active males, urethritis causes dysuria throughout voiding. It’s accompanied by a reddened meatus and copious, yellow, purulent discharge (gonorrheal infection) or white or clear mucoid discharge (nongonorrheal infection).
Urinary obstruction
Outflow obstruction by urethral strictures or calculi produces dysuria throughout voiding. (With complete obstruction, bladder distention develops and dysuria precedes voiding.) Other features include diminished urine stream, urinary frequency and urgency, and a sensation of fullness or bloating in the lower abdomen or groin.
Vaginitis
Characteristically, dysuria occurs throughout voiding as urine touches inflamed or ulcerated labia. Other findings include urinary frequency and urgency, nocturia, hematuria, perineal pain, and vaginal discharge and odor.
Other causes
Chemical irritants
Dysuria may be caused by contact with irritating substances, such as bubble bath salts and feminine deodorants; it’s usually most intense at the end of voiding. Spermicides may cause dysuria in both sexes. Other findings include urinary frequency and urgency, a diminished urine stream and, possibly, hematuria.
Drugs
Dysuria can result from monoamine oxidase inhibitor use. Metyrosine can also cause transient dysuria.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oliguria:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Acute tubular necrosis
An early sign of acute tubular necrosis, oliguria may occur abruptly (in shock) or gradually (in nephrotoxicity). Usually, it persists for about 2 weeks, followed by polyuria. Related features include signs of hyperkalemia (muscle weakness and cardiac arrhythmias), uremia (anorexia, confusion, lethargy, twitching, seizures, pruritus, and Kussmaul’s respirations), and heart failure (edema, jugular vein distention, crackles, and dyspnea).
Calculi
Oliguria or anuria may result from calculi lodging in the kidneys, ureters, bladder outlet, or urethra. Associated signs and symptoms include urinary frequency and urgency, dysuria, and hematuria or pyuria. Usually, the patient experiences renal colic — excruciating pain that radiates from the CVA to the flank, the suprapubic region, and the external genitalia. This pain may be accompanied by nausea, vomiting, hypoactive bowel sounds, abdominal distention and, occasionally, fever and chills.
Glomerulonephritis (acute)
Acute glomerulonephritis produces oliguria or anuria. Other features are mild fever, fatigue, gross hematuria, proteinuria, generalized edema, elevated blood pressure, headache, nausea and vomiting, flank and abdominal pain, and signs of pulmonary congestion (dyspnea and productive cough).
Heart failure
Oliguria may occur in left-sided heart failure as a result of low cardiac output and decreased renal perfusion. Accompanying signs and symptoms include dyspnea, fatigue, weakness, peripheral edema, distended jugular veins, tachycardia, tachypnea, crackles, and a dry or productive cough. In advanced heart failure, the patient may also develop orthopnea, cyanosis, clubbing, ventricular gallop, diastolic hypertension, cardiomegaly, and hemoptysis.
Hypovolemia
Any disorder that decreases circulating fluid volume can produce oliguria. Associated findings in hypovolemia include orthostatic hypotension, apathy, lethargy, fatigue, gross muscle weakness, anorexia, nausea, profound thirst, dizziness, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Pyelonephritis (acute)
Accompanying the sudden onset of oliguria in acute pyelonephritis are high fever with chills, fatigue, flank pain, CVA tenderness, weakness, nocturia, dysuria, hematuria, urinary frequency and urgency, and tenesmus. The urine may appear cloudy. Occasionally, the patient with acute pyelonephritis also experiences anorexia, nausea, diarrhea, and vomiting.
Renal artery occlusion (bilateral)
Renal artery occlusion may produce oliguria or, more commonly, anuria. Other features include severe, constant upper abdominal and flank pain, nausea and vomiting, and hypoactive bowel sounds. The patient also develops a fever 1 to 2 days after the occlusion, as well as diastolic hypertension.
Renal failure (chronic)
Oliguria is a major sign of end-stage chronic renal failure. Associated findings reflect progressive uremia and include fatigue, weakness, irritability, uremic fetor, ecchymoses and petechiae, peripheral edema, elevated blood pressure, confusion, emotional lability, drowsiness, coarse muscle twitching, muscle cramps, peripheral neuropathies, anorexia, metallic taste in the mouth, nausea and vomiting, constipation or diarrhea, stomatitis, pruritus, pallor, and yellow- or bronze-tinged skin. Eventually, seizures, coma, and uremic frost may develop.
Renal vein occlusion (bilateral)
Renal vein occlusion occasionally causes oliguria accompanied by acute low back and flank pain, CVA tenderness, fever, pallor, hematuria, enlarged and palpable kidneys, edema and, possibly, signs of uremia.
Sepsis
Any condition that results in sepsis may produce oliguria, along with fever, chills, restlessness, confusion, diaphoresis, anorexia, vomiting, diarrhea, pallor, hypotension, and tachycardia. The patient may exhibit signs of local infection, such as dysuria and wound drainage. In severe infection, he may develop lactic acidosis marked by Kussmaul’s respirations.
Toxemia of pregnancy
In severe preeclampsia, oliguria may be accompanied by elevated blood pressure, dizziness, diplopia, blurred vision, epigastric pain, nausea and vomiting, irritability, and severe frontal headache. Typically, the oliguria is preceded by generalized edema and sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester or more than 1 lb (0.5 kg) per week during the third trimester. If preeclampsia progresses to eclampsia, the patient develops seizures and may slip into coma.
Urethral stricture
Urethral stricture produces oliguria accompanied by chronic urethral discharge, urinary frequency and urgency, dysuria, pyuria, and diminished urine stream. As obstruction worsens, urine extravasation may lead to formation of urinomas and urosepsis.
Other causes
Diagnostic studies
Radiographic studies that use contrast media may cause nephrotoxicity and oliguria.
Drugs
Oliguria may result from drugs that cause decreased renal perfusion (diuretics), nephrotoxicity (most notably, aminoglycosides and chemotherapeutic drugs), urine retention (adrenergics and anticholinergics), or urinary obstruction associated with precipitation of urinary crystals (sulfonamides and acyclovir).
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Polyuria:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Acute tubular necrosis
During the diuretic phase of acute tubular necrosis, polyuria of less than 8 L/day gradually subsides after 8 to 10 days. Urine specific gravity (1.010 or less) increases as polyuria subsides. Related findings include weight loss, decreasing edema, and nocturia.
Diabetes insipidus
With diabetes insipidus, polyuria of about 5 L/day with a specific gravity of 1.005 or less is common, although extreme polyuria — up to 30 L/day — occasionally occurs. Polyuria is commonly accompanied by polydipsia, nocturia, fatigue, and signs of dehydration, such as poor skin turgor and dry mucous membranes.
Diabetes mellitus
With diabetes mellitus, polyuria seldom exceeds 5 L/day, and urine specific gravity typically exceeds 1.020. The patient usually reports polydipsia, polyphagia, weight loss, weakness, frequent urinary tract infections and yeast vaginitis, fatigue, and nocturia. The patient may also display signs of dehydration and anorexia.
Glomerulonephritis (chronic)
Polyuria gradually progresses to oliguria with chronic glomerulonephritis. Urine output is usually less than 4 L/day; specific gravity is about 1.010. Related GI findings include anorexia, nausea, and vomiting. The patient may experience drowsiness,fatigue, edema, headache, elevated blood pressure, and dyspnea. Nocturia, hematuria, frothy or malodorous urine, and mild to severe proteinuria may also occur.
Hypercalcemia
Elevated plasma calcium levels may lead to nephropathy, usually producing polyuria of less than 5 L/day with a specific gravity of about 1.010. Accompanying signs and symptoms include polydipsia, nocturia, constipation, paresthesia and, occasionally, hematuria, and pyuria. With severe hypercalcemia, the patient’s condition worsens rapidly and he experiences anorexia, vomiting, stupor progressing to coma, and renal failure.
Hypokalemia
Prolonged potassium depletion may lead to nephropathy, which results in polyuria — usually less than 5 L/day with a specific gravity of about 1.010. Associated findings include polydipsia, circumoral and foot paresthesia, hypoactive deep tendon reflexes, fatigue, hypoactive bowel sounds, nocturia, arrhythmias, and muscle cramping, weakness, or paralysis.
Postobstructive uropathy
After resolution of a urinary tract obstruction, polyuria — usually more than 5 L/day with a specific gravity of less than 1.010 — occurs for up to several days before gradually subsiding. Bladder distention and edema may occur with nocturia and weight loss. Occasionally, signs of dehydration appear.
Pyelonephritis
Acute pyelonephritis usually results in polyuria of less than 5 L/day with a low but variable specific gravity. Other findings include persistent high fever, flank pain (usually unilateral), hematuria, costovertebral angle tenderness, chills, weakness, dysuria, urinary frequency and urgency, tenesmus, and nocturia. Occasionally, nausea, anorexia, vomiting, and hypoactive bowel sounds occur.
Chronic pyelonephritis produces polyuria of less than 5 L/day that declines as renal function worsens. Urine specific gravity is usually about 1.010 but may be higher if proteinuria is present. Other effects include irritability, paresthesia, fatigue, nausea, vomiting, diarrhea, drowsiness, anorexia, pyuria and, in late stages, elevated blood pressure.
Sickle cell anemia
Sickle cell anemia may cause nephropathy, typically producing polyuria of less than 5 L/day with a specific gravity of about 1.020. Additional findings include polydipsia, fatigue, abdominal cramps, arthralgia, priapism and, occasionally, leg ulcers and bony deformities.
Other causes
Diagnostic tests
Transient polyuria can result from radiographic tests that use contrast media.
Drugs
Diuretics characteristically produce polyuria. Cardiotonics, vitamin D, demeclocycline, phenytoin, lithium, methoxyflurane, and propoxyphene can also produce polyuria.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary frequency:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Benign prostatic hyperplasia
With benign prostatis hyperplasia (BPH), prostatic enlargement causes urinary frequency, along with nocturia and possibly incontinence and hematuria. Initial effects are reduced caliber and force of the urine stream, urinary hesitancy and tenesmus, inability to stop the urine stream, a feeling of incomplete voiding, and occasionally urine retention. Assessment reveals bladder distention.
Bladder calculus
Bladder irritation may lead to urinary frequency and urgency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. The patient may have overflow incontinence if the calculus lodges in the bladder neck. Greatest discomfort usually occurs at the end of micturition if the stone lodges in the bladder neck. This may also cause overflow incontinence and referred pain to the lower back or heel.
Bladder cancer
Urinary frequency, urgency, dribbling, and nocturia may develop from bladder irritation; however, the first sign of bladder cancer commonly is gross, painless, intermittent hematuria (usually with clots). Patients with invasive lesions commonly have suprapubic or pelvic pain from bladder spasms.
Multiple sclerosis
Urinary frequency, urgency, and incontinence are common urologic findings in patients with multiple sclerosis. Typically, visual problems (such as diplopia and blurred vision) and sensory impairment (such as paresthesia) are the earliest symptoms. Other findings may include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer
In advanced stages of prostate cancer, urinary frequency may occur, along with hesitancy, dribbling, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped prostate.
Prostatitis
Acute prostatitis commonly produces urinary frequency, along with urgency, dysuria, nocturia, and purulent urethral discharge. Other findings include fever, chills, low back pain, myalgia, arthralgia, and perineal fullness. The prostate may be tense, boggy, tender, and warm. Signs and symptoms of chronic prostatitis are usually the same as those of the acute form, but to a lesser degree. The patient may also experience pain on ejaculation.
Rectal tumor
The pressure exerted by a rectal tumor on the bladder may cause urinary frequency. Early findings include changed bowel habits, commonly starting with an urgent need to defecate on arising or obstipation alternating with diarrhea; blood or mucus in the stool; and a sense of incomplete evacuation.
Reiter’s syndrome
Reiter’s syndrome is a self-limiting syndrome in which urinary frequency occurs with symptoms of acute urethritis 1 to 2 weeks after sexual contact. Other symptoms include asymmetrical arthritis of knees, ankles, and metatarsophalangeal joints; unilateral or bilateral conjunctivitis; and small painless ulcers on the mouth, tongue, glans penis, palms of the hands, and soles of the feet.
Reproductive tract tumor
A tumor in the female reproductive tract may compress the bladder, causing urinary frequency. Other findings vary but may include abdominal distention, menstrual disturbances, vaginal bleeding, weight loss, pelvic pain, and fatigue.
Spinal cord lesion
Incomplete spinal cord transection results in urinary frequency, continuous overflow, dribbling, urgency when voluntary control of sphincter function weakens, urinary hesitancy, and bladder distention. Other effects occur below the level of the lesion and include weakness, paralysis, sensory disturbances, hyperreflexia, and impotence.
Urethral stricture
Bladder decompensation produces urinary frequency, along with urgency and nocturia. Early signs include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence may occur. Urinoma and urosepsis may develop.
Urinary tract infection
UTI is a common cause of urinary frequency. It may also produce urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. The patient may report bladder spasms or a feeling of warmth during urination and a fever.
Other causes
Diuretics
Diuretics, which include caffeine, reduce the body’s total volume of water and salt by increasing urine excretion. Excessive intake of coffee, tea, and other caffeinated beverages leads to urinary frequency.
Treatments
Radiation therapy may cause bladder inflammation, leading to urinary frequency.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary hesitancy:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Benign prostatic hyperplasia
Characteristic early findings of benign prostatic hyperplasia (BPH) include urinary hesitancy, reduced caliber and force of urine stream, perineal pain, a feeling of incomplete voiding, inability to stop the urine stream and, occasionally, urine retention. As obstruction increases, urination becomes more frequent, with nocturia, urinary overflow, incontinence, bladder distention, and possibly hematuria.
Prostate cancer
In patients with advanced prostate cancer, urinary hesitancy may occur, accompanied by frequency, dribbling, nocturia, dysuria, bladder distention, perineal pain, and constipation. Digital rectal examination commonly reveals a hard, nodular prostate.
Spinal cord lesion
A lesion below the micturition center that has destroyed the sacral nerve roots causes urinary hesitancy, tenesmus, and constant dribbling from retention and overflow incontinence. Associated findings are urinary frequency and urgency, dysuria, and nocturia.
Urethral stricture
Partial obstruction of the lower urinary tract produces urinary hesitancy, tenesmus, and decreased force and caliber of the urine stream. Urinary frequency and urgency, nocturia, and eventually overflow incontinence may develop. Pyuria usually indicates accompanying infection. Increased obstruction may lead to urine extravasation and formation of urinomas.
Urinary tract infection
Urinary hesitancy may be associated UTI. Characteristic urinary changes include frequency, possible hematuria, dysuria, nocturia, and cloudy urine. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, pelvic, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Drugs
Anticholinergics and drugs with anticholinergic properties (such as tricyclic antidepressants and some nasal decongestants and cold remedies) may cause urinary hesitancy. Urinary hesitancy also may occur in those recovering from general anesthesia.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary incontinence:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Benign prostatic hyperplasia
Overflow incontinence is common with benign prostatic hyperplasia (BPH) as a result of urethral obstruction and urine retention. The disorder begins with a group of signs and symptoms known as prostatism: reduced caliber and force of urine stream, urinary hesitancy, and a feeling of incomplete voiding. As obstruction increases, urination becomes more frequent, with nocturia and, possibly, hematuria. Examination reveals bladder distention and an enlarged prostate.
Bladder calculus
Overflow incontinence may occur if the stone lodges in the bladder neck. Associated findings vary but may include those of an irritable bladder: urinary frequency and urgency, dysuria, hematuria, and suprapubic pain from bladder spasms. Pelvic pain and pain referred to the tip of the penis, vulva, low back, or heel may occur. Pain may be exacerbated by movement.
Bladder cancer
With bladder cancer, the patient commonly presents with urge incontinence and hematuria; obstruction by a tumor may produce overflow incontinence. Symptoms may be absent during the early stages. Other urinary signs and symptoms include frequency, dysuria, nocturia, dribbling, and suprapubic pain from bladder spasms after voiding. A mass may be palpable on bimanual examination.
Diabetic neuropathy
Diabetic neuropathy may cause painless bladder distention with overflow incontinence. Related findings include episodic constipation or diarrhea (which is commonly nocturnal), impotence and retrograde ejaculation, orthostatic hypotension, syncope, and dysphagia.
Guillain-Barré syndrome
Urinary incontinence may occur early in Guillain-Barré syndrome as a result of peripheral and autonomic nerve dysfunction. The most prominent sign is progressive, profound muscle weakness, which typically starts in the legs and extends to the arms and facial nerves within 24 to 72 hours. Associated findings include paresthesia; dysarthria; nasal speech; dysphagia; orthostatic hypotension; fecal incontinence; diaphoresis; drooling; pain in the shoulders, thighs, or lumbar region; and tachycardia.
Multiple sclerosis
Urinary incontinence, urgency, and frequency are common urologic findings in multiple sclerosis. In most patients, vision problems and sensory impairment occur early. Other findings include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer
Urinary incontinence usually appears only in the advanced stages of prostate cancer. Urinary frequency and hesitancy, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped, nodular prostate are other common late findings.
Prostatitis (chronic)
Urinary incontinence may occur as a result of urethral obstruction from an enlarged prostate. Other findings include urinary frequency and urgency, dysuria, hematuria, bladder distention, persistent urethral discharge, dull perineal pain that may radiate, ejaculatory pain, and decreased libido.
Spinal cord injury
Complete spinal cord transection above the sacral level causes flaccid paralysis of the bladder. Overflow incontinence follows rapid bladder distention. Other findings include paraplegia, sexual dysfunction, sensory loss, muscle atrophy, anhidrosis, and loss of reflexes distal to the injury.
Stroke
Urinary incontinence may be transient or permanent in stroke patients. Associated findings reflect the site and extent of the lesion and may include impaired mentation, emotional lability, behavioral changes, altered level of consciousness, and seizures. Headache, vomiting, visual deficits, and decreased visual acuity are possible. Sensorimotor effects include contralateral hemiplegia, dysarthria, dysphagia, ataxia, apraxia, agnosia, aphasia, and unilateral sensory loss.
Urethral stricture
Eventually, overflow incontinence may occur with urethral stricture. As obstruction increases, urine extravasation may lead to formation of urinomas and urosepsis.
Urinary tract infection
Besides incontinence, a UTI may produce urinary urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. Bladder spasms or a feeling of warmth during urination may occur.
Other causes
Surgery
Urinary incontinence may occur after prostatectomy as a result of urethral sphincter damage.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Urinary urgency:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Bladder calculus
Bladder irritation from a calculus can lead to urinary urgency and frequency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. Pain may be referred to the penis, vulva, lower back, or heel.
Multiple sclerosis
Urinary urgency can occur with or without the frequent UTIs that can accompany multiple sclerosis. Commonly, visual and other sensory impairments are the earliest findings. Other findings include urinary frequency, incontinence, constipation, muscle weakness, paralysis, spasticity, intention tremor, hyperreflexia, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability.
Reiter’s syndrome
Reiter’s syndrome is a self-limiting syndrome that primarily affects males. Urgency occurs with other symptoms of acute urethritis 1 to 2 weeks after sexual contact. Arthritic and ocular symptoms and skin lesions usually develop within several weeks after sexual contact. These symptoms include asymmetrical arthritis of knees, ankles, or metatarsal phalangeal joints; conjunctivitis; and ulcers on the penis, or skin, or in the mouth.
Spinal cord lesion
Urinary urgency can result from incomplete spinal cord transection when voluntary control of sphincter function weakens. Urinary frequency, difficulty initiating and inhibiting a urine stream, and bladder distention and discomfort may also occur. Neuromuscular effects distal to the lesion include weakness, paralysis, hyperreflexia, sensory disturbances, and impotence.
Urethral stricture
Bladder decompensation produces urinary urgency, frequency, and nocturia. Early signs and symptoms include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence may occur.
Urinary tract infection
Urinary urgency is commonly associated with a UTI. Other characteristic urinary changes include frequency, hematuria, dysuria, nocturia, and cloudy urine. Urinary hesitancy may also occur. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Treatments
Radiation therapy may irritate and inflame the bladder, causing urinary urgency.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Cough, barking:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Aspiration of foreign body
Partial obstruction of the upper airway caused by aspiration of foreign body first produces sudden hoarseness, then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.
Epiglottiditis
Epiglottiditis, a life-threatening disorder, has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.
Laryngotracheobronchitis (acute)
Also known as viral croup, acute laryngotracheobronchitis is most common in children between 9 and 18 months old and usually occurs in the fall and early winter. It initially produces low to moderate fever, runny nose, poor appetite, and infrequent cough. When the infection descends into the laryngotracheal area, barking cough, hoarseness, and inspiratory stridor occur.
As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.
Spasmodic croup
Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn’t have a fever but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Cough, nonproductive:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Airway occlusion
Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds. If the patient has aspirated a foreign body he may exhibit the universal sign for choking — a hand clutched to the throat, with thumb and fingers extended.
Anthrax (inhalation)
Inhalation anthrax is caused by inhalation of aerosolized spores of the gram-positive bacterium Bacillus anthracis. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
Aortic aneurysm (thoracic)
A thoracic aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, neck vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.
Asthma
Asthma attacks commonly occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.
Atelectasis
As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient with atelectasis may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.
Bronchitis (chronic)
Chronic bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.
Bronchogenic carcinoma
The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough, dyspnea, and vague chest pain. The patient may also have wheezing, hemoptysis, and stridor.
Common cold
The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headache, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and sore throat.
Esophageal achalasia
With esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia. The patient may report weight loss, heartburn, and chest pain that increases after eating.
Esophageal diverticula
The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.
Esophageal occlusion
Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.
Esophagitis with reflux
Esophagitis with reflux commonly causes a nonproductive nocturnal cough due to regurgitation and aspiration. The patient may experience chest pain that mimics angina pectoris; heartburn that worsens if he lies down after eating; and increased salivation, dysphagia, hematemesis, and melena.
Hodgkin’s disease
Hodgkin’s disease may cause a crowing nonproductive cough. However, the earliest sign is usually painless swelling of one of the cervical lymph nodes or, occasionally, of the axillary, mediastinal, or inguinal lymph nodes. Another early sign is pruritus. Other findings depend on the degree and location of systemic involvement and include dyspnea, dysphagia, hepatosplenomegaly, edema, jaundice, nerve pain, and hyperpigmentation.
Hypersensitivity pneumonitis
With hypersensitivity pneumonitis, an acute nonproductive cough, fever, dyspnea, and malaise usually occur 5 to 6 hours after exposure to an antigen. The patient may also report chest tightness and extreme fatigue.
Interstitial lung disease
A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss. Other findings include dyspnea on exertion and vague chest pain.
Laryngeal tumor
A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and earache may occur.
Laryngitis
In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.
Legionnaires’ disease
After a prodrome of malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness, legionnaires’disease causes a nonproductive cough that later produces mucoid, mucopurulent and, possibly, bloody sputum.
Lung abscess
Lung abscess typically begins with nonproductive coughing, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, fever, headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling, possibly bloody sputum.
Mediastinal tumor
A large mediastinal tumor produces a nonproductive cough, dyspnea, and retrosternal pain. The patient may also develop stertorous respirations with suprasternal retraction on inspiration, hoarseness, dysphagia, tracheal shift or tug, neck vein distention, and facial or neck edema.
Pleural effusion
A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.
Pneumonia
Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, headache, high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient’s chest may be dull on percussion.
With mycoplasma pneumonia, a nonproductive cough arises 2 to 3 days after the onset of malaise, headache, and sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn’t appear seriously ill.
Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and low-grade fever.
Pneumothorax
Pneumothorax, a life-threatening disorder, causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.
Pulmonary edema
Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, and ventricular gallop. If pulmonary edema is severe, the patient’s respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.
Pulmonary embolism
A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. More commonly, though, the cough produces blood-tinged sputum. Tachycardia and low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.
Sarcoidosis
With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, vision impairment, difficulty swallowing, and arrhythmias.
CULTURAL CUE:The risk of sarcoidosis is greatest in young adult Blacks, especially Black women. Others at high risk include those of Scandinavian, German, Irish, or Puerto Rican descent.
Severe acute respiratory syndrome
The incubation period of this acute infectious disease of unknown etiology is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms of severe acute respiratory syndrome (SARS) include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.
CULTURAL CUE:Most cases of SARS have been reported in Asia (China, Vietnam, Singapore, Thailand), although some cases have appeared in Europe and North America.
Sinusitis (chronic)
Chronic sinusitis can cause a chronic nonproductive cough due to postnasal drip. The patient’s nasal mucosa may appear inflamed, and he may have nasal congestion and profuse drainage. Usually, his breath smells musty.
Tracheobronchitis (acute)
Initially, acute tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, sore throat, slight fever, muscle and back pain, and substernal tightness generally precede the cough’s onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° F to 102° F (38.3° to 38.9° C) and possibly bronchospasm, with severe wheezing and increased coughing.
Tularemia
Following inhalation of the gram-negative, non-spore-forming bacterium Francisella tularensis, patients with tularemia show signs and symptoms including the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Diagnostic tests
Pulmonary function tests and bronchoscopy may stimulate cough receptors, triggering coughing.
Treatments
Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Cough, productive:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Aspiration pneumonitis
Aspiration pneumonitis causes coughing that produces pink, frothy, possibly purulent sputum. The patient also has marked dyspnea, fever, tachypnea, fatigue, chest pain, halitosis, tachycardia, wheezing, and cyanosis.
Asthma (acute)
A severe asthma attack, which can be life-threatening, may produce mucoid, tenacious sputum and mucus plugs. Such an attack typically starts with a dry cough and mild wheezing, then progresses to severe dyspnea, audible wheezing, chest tightness, and a productive cough. Other findings include apprehension, prolonged expirations, intercostal and supraclavicular retraction on inspiration, accessory muscle use, rhonchi, crackles, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis. Attacks commonly occur at night or during sleep.
Bronchiectasis
The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger clubbing.
Bronchitis (chronic)
Chronic bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.
The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.
Chemical pneumonitis
Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.
Common cold
When a common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications of the common cold include a dry, hacking cough, sneezing, headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, sore throat, myalgia, and arthralgia.
Legionnaires’ disease
Legionnaires’ disease causes a cough that produces scant mucoid, nonpurulent, possibly blood-streaked sputum. Prodromal signs and symptoms typically include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly, diarrhea. Then, within 48 hours, the patient develops a dry cough and a sudden high fever with chills. Many patients also have pleuritic chest pain, headache, tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis, and prostration.
Lung abscess (ruptured)
The cardinal sign of ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling, possibly blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, fever with chills, dyspnea, headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient’s chest is dull on percussion on the affected side.
Lung cancer
One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, fever, diaphoresis, wheezing, and clubbing.
Plague
Signs and symptoms of plague, caused by the bacterium Yersinia pestis, include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The onset of the pneumonic form is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pneumonia
Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.
Pulmonary edema
Severe, pulmonary edema is a life-threatening disorder that causes a cough that produces frothy, bloody sputum. Early signs and symptoms of pulmonary edema include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.
Pulmonary embolism
Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and distended neck veins. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.
Pulmonary emphysema
Pulmonary emphysema causes a chronic productive cough with scant, mucoid, translucent, grayish white sputum that can become mucopurulent. The patient is thin and has the characteristic “pink puffer” appearance with weight loss, increased accessory muscle use, tachypnea, grunting expirations through pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, and anorexia. Clubbing is a late sign.
Pulmonary tuberculosis
Pulmonary tuberculosis causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.
Silicosis
A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.
Tracheobronchitis
With tracheobronchitis, inflammation initially causes a nonproductive cough that later — following the onset of chills, sore throat, slight fever, muscle and back pain, and substernal tightness — becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.
Other causes
Diagnostic tests
Bronchoscopy and pulmonary function tests may increase productive coughing.
Drugs
Expectorants, of course, increase productive coughing. These include guaifenesin, potassium iodide, and terpin hydrate.
Respiratory therapy
Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Cough:
Principal Causes of Cough
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Infection/inflammation
- Upperrespiratory tract infection
- Sinusitis
- Laryngitis
- Croup
- Tracheitis
- Bronchitis
- Pertussis
- Bronchiolitis
- Pneumonia
- Viral
- Bacterial
- Tuberculosis
- Chlamydia
- Legionella
- Nocardia
- Mycoplasma
- Fungal
- Histoplasmosis
- Coccidioidomycosis
- Aspergillosis
- Blastomycosis
- Protozoa
- Chemical pneumonia
- Aspiration pneumonia
- Cystic fibrosis
- Bronchiectasis
- Lung abscess
- Allergic disorders
- Allergicrhinitis
- Asthma
- Mechanical or chemical irritation
- Environmentalirritants
- Foreign body aspiration
- Bronchopulmonary dysplasia
- Congenital anomalies
- Cardiac failure
- Gastroesophageal reflux
- Swallowing dysfunction
- Immotile cilia syndrome
- Neoplasm
- Reflex cough
- Psychogenic, including habitual cough
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysuria:
Principal Causes of Dysuria
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Urinarytract infection
- Urethritis
- Cystitis
- Pyelonephritis
- Chemical irritation
- Diaper dermatitis
- Trauma
- Psychogenic
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Proteinuria:
Principal Causes of Proteinuria
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Functional/transientproteinuria
- Fever
- Strenuous exercise
- Extreme cold
- Cardiac failure
- Seizures
- Emotional stress
- Postural proteinuria (orthostatic)
- Nephrotic syndrome
- Tubulointerstitial disease
- Refluxnephropathy
- Tubulointerstitial nephritis
- Fanconi syndrome
- Ischemic tubular injury
- Benign persistent proteinuria
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Urinary Incontinence:
Principal Causes of Urinary Incontinence
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Maturationaldelay
- Stress-related causes
- Urinary tract disorders
- Urinarytract infection
- Dysfunctional voiding disorders
- Lower urinary tract obstruction
- Ectopic ureter in girls
- Neurologic disorders
- Mentalretardation
- Neurogenic bladder
- Abdominal or pelvic mass
- Polyuria
- Primary psychologic disturbance
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Polyuria and Polydipsia:
Principal Causes of Polyuria and Polydipsia
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Diabetesmellitus
- Diabetes insipidus
- Antidiuretichormone deficiency (central diabetes insipidus)
- Antidiuretic hormone resistance (nephrogenicdiabetes insipidus)
- Primary polydipsia
- Compulsivewater drinking
- Hypothalamic thirst center defect
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysuria:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Appendicitis.Occasionally, appendicitis causes dysuria that persists throughout voiding and is accompanied by bladder tenderness. Appendicitis is characterized by periumbilical abdominal pain that shifts to McBurney's point, anorexia, nausea, vomiting, constipation, a slight fever, abdominal rigidity and rebound tenderness, and tachycardia.
Bladder cancer.Bladder cancer, a predominantly male disorder, causes dysuria throughout voiding—a late symptom associated with urinary frequency and urgency, nocturia, hematuria, and perineal, back, or flank pain.
Cystitis.Dysuria throughout voiding is common in all types of cystitis, as are urinary frequency, nocturia, straining to void, and hematuria. Bacterial cystitis, the most common cause of dysuria in women, may also produce urinary urgency, perineal and lower back pain, suprapubic discomfort, fatigue and, possibly, a low-grade fever. With chronic interstitial cystitis, dysuria is accentuated at the end of voiding. In tubercular cystitis, symptoms may also include urinary urgency, flank pain, fatigue, and anorexia. With viral cystitis, severe dysuria occurs with gross hematuria, urinary urgency, and a fever.
Paraurethral gland inflammation.Dysuria throughout voiding occurs with urinary frequency and urgency, a diminished urine stream, mild perineal pain and, occasionally, hematuria.
Prostatitis.Acute prostatitis commonly causes dysuria throughout or toward the end of voiding as well as a diminished urine stream, urinary frequency and urgency, hematuria, suprapubic fullness, a fever, chills, fatigue, myalgia, nausea, vomiting, and constipation. With chronic prostatitis, urethral narrowing causes dysuria throughout voiding. Related effects are urinary frequency and urgency; a diminished urine stream; perineal, back, and buttock pain; urethral discharge; nocturia; and, at times, hematospermia and ejaculatory pain.
Pyelonephritis (acute).Pyelonephritis causes dysuria throughout voiding. Other features include a persistent high fever with chills, costovertebral angle tenderness, unilateral or bilateral flank pain, weakness, urinary urgency and frequency, nocturia, straining on urination, and hematuria. Nausea, vomiting, and anorexia may also occur.
Reiter's syndrome.Reiter's syndrome is a disorder in which dysuria occurs 1 or 2 weeks after sexual contact. Initially, the patient has a mucopurulent discharge, urinary urgency and frequency, meatal swelling and redness, suprapubic pain, anorexia, weight loss, and a low-grade fever. Hematuria, conjunctivitis, arthritic symptoms, a papular rash, and oral and penile lesions may follow.
Urinary obstruction.Outflow obstruction by urethral strictures or calculi produces dysuria throughout voiding. (With complete obstruction, bladder distention develops and dysuria precedes voiding.) Other features are a diminished urine stream, urinary frequency and urgency, and a sensation of fullness or bloating in the lower abdomen or groin.
Vaginitis.Characteristically, dysuria occurs throughout voiding as urine touches inflamed or ulcerated labia with vaginitis. Other findings include urinary frequency and urgency, nocturia, hematuria, perineal pain, and vaginal discharge and odor.
Other causes
Chemical irritants.Dysuria may result from irritating substances, such as bubble bath salts and feminine deodorants; it's usually most intense at the end of voiding. Spermicides may cause dysuria in both sexes. Other findings include urinary frequency and urgency, a diminished urine stream and, possibly, hematuria.
Drugs.Dysuria can result from monoamine oxidase inhibitors. Metyrosine can also cause transient dysuria.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Oliguria:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Acute tubular necrosis (ATN).An early sign of ATN, oliguria may occur abruptly (in shock) or gradually (in nephrotoxicity). Usually, it persists for about 2 weeks, followed by polyuria. Related features include signs of hyperkalemia (muscle weakness and cardiac arrhythmias), uremia (anorexia, confusion, lethargy, twitching, seizures, pruritus, and Kussmaul's respirations), and heart failure (edema, jugular vein distention, crackles, and dyspnea).
Calculi.Oliguria or anuria may result from calculi lodging in the kidneys, ureters, bladder outlet, or urethra. Associated signs and symptoms include urinary frequency and urgency, dysuria, and hematuria or pyuria. Usually, the patient experiences renal colic—excruciating pain that radiates from the CVA to the flank, the suprapubic region, and the external genitalia. This pain may be accompanied by nausea, vomiting, hypoactive bowel sounds, abdominal distention and, occasionally, fever and chills.
Cholera. With cholera, severe water and electrolyte loss lead to oliguria, thirst, weakness, muscle cramps, decreased skin turgor, tachycardia, hypotension, and abrupt watery diarrhea and vomiting. Death may occur in hours without treatment.
Glomerulonephritis (acute).Acute glomerulonephritis produces oliguria or anuria. Other features are a mild fever, fatigue, gross hematuria, proteinuria, generalized edema, elevated blood pressure, headache, nausea and vomiting, flank and abdominal pain, and signs of pulmonary congestion (dyspnea and a productive cough).
Heart failure.Oliguria may occur with left-sided heart failure as a result of low cardiac output and decreased renal perfusion. Accompanying signs and symptoms include dyspnea, fatigue, weakness, peripheral edema, jugular vein distention, tachycardia, tachypnea, crackles, and a dry or productive cough. With advanced or chronic heart failure, the patient may also develop orthopnea, cyanosis, clubbing, a ventricular gallop, diastolic hypertension, cardiomegaly, and hemoptysis.
Hypovolemia. Any disorder that decreases circulating fluid volume can produce oliguria. Associated findings include orthostatic hypotension, apathy, lethargy, fatigue, gross muscle weakness, anorexia, nausea, profound thirst, dizziness, sunken eyeballs, poor skin turgor, and dry mucous membranes.
Pyelonephritis (acute).Accompanying the sudden onset of oliguria with acute pyelonephritis are a high fever with chills, fatigue, flank pain, CVA tenderness, weakness, nocturia, dysuria, hematuria, urinary frequency and urgency, and tenesmus. The urine may appear cloudy. Occasionally, the patient also experiences anorexia, diarrhea, and nausea and vomiting.
Renal failure (chronic).Oliguria is a major sign of end-stage chronic renal failure. Associated findings reflect progressive uremia and include fatigue, weakness, irritability, uremic fetor, ecchymoses and petechiae, peripheral edema, elevated blood pressure, confusion, emotional lability, drowsiness, coarse muscle twitching, muscle cramps, peripheral neuropathies, anorexia, a metallic taste in the mouth, nausea and vomiting, constipation or diarrhea, stomatitis, pruritus, pallor, and yellow- or bronze-tinged skin. Eventually, seizures, coma, and uremic frost may develop.
Renal vein occlusion (bilateral).Bilateral renal vein occlusion occasionally causes oliguria accompanied by acute low back and flank pain, CVA tenderness, fever, pallor, hematuria, enlarged and palpable kidneys, edema and, possibly, signs of uremia.
Toxemia of pregnancy.With severe preeclampsia, oliguria may be accompanied by elevated blood pressure, dizziness, diplopia, blurred vision, epigastric pain, nausea and vomiting, irritability, and a severe frontal headache. Typically, oliguria is preceded by generalized edema and sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester, or more than 1 lb (0.45 kg) per week during the third trimester. If preeclampsia progresses to eclampsia, the patient develops seizures and may slip into coma.
Urethral stricture.Urethral stricture produces oliguria accompanied by chronic urethral discharge, urinary frequency and urgency, dysuria, pyuria, and a diminished urine stream. As the obstruction worsens, urine extravasation may lead to formation of urinomas and urosepsis.
Other causes
Diagnostic studies.Radiographic studies that use contrast media may cause nephrotoxicity and oliguria.
Drugs.Oliguria may result from drugs that cause decreased renal perfusion (diuretics), nephrotoxicity (most notably, aminoglycosides and chemotherapeutic drugs), urine retention (adrenergics and anticholinergics), or urinary obstruction associated with precipitation of urinary crystals (sulfonamides and acyclovir).
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Polyuria:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Acute tubular necrosis (ATN).During the diuretic phase of ATN, polyuria of less than 8 L/day gradually subsides after 8 to 10 days. Urine specific gravity (1.010 or less) increases as polyuria subsides. Related findings include weight loss, decreasing edema, and nocturia.
Diabetes insipidus (DI).Polyuria of about 5 L/day with a specific gravity of 1.005 or less is common with DI, although extreme polyuria—up to 30 L/day—occasionally occurs. Polyuria is commonly accompanied by polydipsia, nocturia, fatigue, and signs of dehydration, such as poor skin turgor and dry mucous membranes.
Diabetes mellitus (DM).With DM, polyuria seldom exceeds 5 L/day, and urine specific gravity typically exceeds 1.020. The patient usually reports polydipsia, polyphagia, weight loss, weakness, frequent urinary tract infections and yeast vaginitis, fatigue, and nocturia. The patient may also display signs of dehydration and anorexia.
Glomerulonephritis (chronic).Polyuria gradually progresses to oliguria with chronic glomerulonephritis. Urine output is usually less than 4 L/day; specific gravity is about 1.010. Related GI findings include anorexia, nausea, and vomiting. The patient may experience drowsiness, fatigue, edema, headache, elevated blood pressure, and dyspnea. Nocturia, hematuria, frothy or malodorous urine, and mild to severe proteinuria may occur.
Postobstructive uropathy.After resolution of a urinary tract obstruction, polyuria—usually more than 5 L/day with a specific gravity of less than 1.010—occurs for up to several days before gradually subsiding. Bladder distention and edema may occur with nocturia and weight loss. Occasionally, signs of dehydration appear.
Psychogenic polydipsia.Psychogenic polydipsia usually produces dilute polyuria of 3 to 15 L/day, depending on fluid intake. The patient may appear depressed and have a headache and blurred vision. Weight gain, edema, elevated blood pressure and, occasionally, stupor or coma may develop. With severe overhydration, signs of heart failure may present.
Other causes
Diagnostic tests.Transient polyuria can result from radiographic tests that use contrast media.
Drugs.Diuretics characteristically produce polyuria. Cardiotonics, vitamin D, demeclocycline, phenytoin, lithium, methoxyflurane, and propoxyphene can also produce polyuria.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary frequency:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Benign prostatic hyperplasia.Prostatic enlargement causes urinary frequency, along with nocturia and possibly incontinence and hematuria. Initial effects are those of prostatism: reduced caliber and force of the urine stream, urinary hesitancy and tenesmus, inability to stop the urine stream, a feeling of incomplete voiding, and occasionally urine retention. Assessment reveals bladder distention.
Bladder calculus.Bladder irritation may lead to urinary frequency and urgency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. The patient may have overflow incontinence if the calculus lodges in the bladder neck. Greatest discomfort usually occurs at the end of micturition if the calculus lodges in the bladder neck. This may also cause overflow incontinence and referred pain to the lower back or heel.
Prostate cancer.In advanced stages of prostate cancer, urinary frequency may occur, along with hesitancy, dribbling, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped prostate.
Prostatitis.Acute prostatitis commonly produces urinary frequency, along with urgency, dysuria, nocturia, and purulent urethral discharge. Other findings include fever, chills, low back pain, myalgia, arthralgia, and perineal fullness. The prostate may be tense, boggy, tender, and warm. Prostate massage to obtain prostatic fluid is contraindicated. Signs and symptoms of chronic prostatitis are usually the same as those of the acute form, but to a lesser degree. The patient may also experience pain on ejaculation.
Rectal tumor.The pressure exerted by a rectal tumor on the bladder may cause urinary frequency. Early findings include changed bowel habits, commonly starting with an urgent need to defecate on arising or obstipation alternating with diarrhea; blood or mucus in the stools; and a sense of incomplete evacuation.
Reiter's syndrome.In Reiter's syndrome, urinary frequency occurs with symptoms of acute urethritis 1 to 2 weeks after sexual contact. Other symptoms of this self-limiting syndrome include asymmetrical arthritis of knees, ankles, and metatarsophalangeal joints; unilateral or bilateral conjunctivitis; and small painless ulcers on the mouth, tongue, glans penis, palms, and soles.
Reproductive tract tumor.A tumor in the female reproductive tract may compress the bladder, causing urinary frequency. Other findings vary but may include abdominal distention, menstrual disturbances, vaginal bleeding, weight loss, pelvic pain, and fatigue.
Spinal cord lesion.Incomplete cord transection results in urinary frequency, continuous overflow, dribbling, urgency when voluntary control of sphincter function weakens, urinary hesitancy, and bladder distention. Other effects occur below the level of the lesion and include weakness, paralysis, sensory disturbances, hyperreflexia, and impotence.
Urethral stricture.Bladder decompensation produces urinary frequency, along with urgency and nocturia. Early signs include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence may occur. Urinoma and urosepsis may develop.
Urinary tract infection.Affecting the urethra, the bladder, or the kidneys, this common cause of urinary frequency may also produce urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. The patient may report bladder spasms or a feeling of warmth and pain during urination and fever. Women may experience suprapubic or pelvic pain.
Other causes
Diuretics.Diuretics, which include caffeine, reduce the body's total volume of water and salt by increasing urine excretion. Excessive intake of coffee, tea, and other caffeinated beverages leads to urinary frequency.
Treatments.Radiation therapy may cause bladder inflammation, leading to urinary frequency.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary hesitancy:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Benign prostatic hyperplasia (BPH).Signs and symptoms of BPH depend on the extent of prostatic enlargement and the lobes affected. Characteristic early findings include urinary hesitancy, reduced caliber and force of urine stream, perineal pain, a feeling of incomplete voiding, inability to stop the urine stream and, occasionally, urine retention. As obstruction increases, urination becomes more frequent, with nocturia, urinary overflow, incontinence, bladder distention, and possibly hematuria.
Prostatic cancer.In patients with advanced prostate cancer, urinary hesitancy may occur, accompanied by frequency, dribbling, nocturia, dysuria, bladder distention, perineal pain, and constipation. Digital rectal examination commonly reveals a hard, nodular prostate.
Spinal cord lesion.A lesion below the micturition center that has destroyed the sacral nerve roots causes urinary hesitancy, tenesmus, and constant dribbling from retention and overflow incontinence. Associated findings are urinary frequency and urgency, dysuria, and nocturia.
Urethral stricture.Partial obstruction of the lower urinary tract secondary to trauma or infection produces urinary hesitancy, tenesmus, and decreased force and caliber of the urine stream. Urinary frequency and urgency, nocturia, and eventually overflow incontinence may develop. Pyuria usually indicates accompanying infection. Increased obstruction may lead to urine extravasation and formation of urinomas.
UTI.Urinary hesitancy may be associated with a UTI. Characteristic urinary changes include frequency, possible hematuria, dysuria, nocturia, and cloudy urine. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, pelvic, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Drugs.Anticholinergics and drugs with anticholinergic properties (such as tricyclic antidepressants and some nasal decongestants and cold remedies) may cause urinary hesitancy. Hesitancy may also occur in those recovering from general anesthesia.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary incontinence:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Benign prostatic hyperplasia (BPH).Overflow incontinence is common with BPH as a result of urethral obstruction and urine retention. BPH begins with a group of signs and symptoms known as prostatism: reduced caliber and force of urine stream, urinary hesitancy, and a feeling of incomplete voiding. As obstruction increases, urination becomes more frequent, with nocturia and, possibly, hematuria. Examination reveals bladder distention and an enlarged prostate.
Bladder cancer.With bladder cancer, the patient commonly presents with urge incontinence and hematuria; obstruction by a tumor may produce overflow incontinence. The early stages may not produce symptoms. Other urinary signs and symptoms include frequency, dysuria, nocturia, dribbling, and suprapubic pain from bladder spasms after voiding. A mass may be palpable on bimanual examination.
Diabetic neuropathy.Autonomic neuropathy may cause painless bladder distention with overflow incontinence. Related findings include episodic constipation or diarrhea (which is commonly nocturnal), impotence and retrograde ejaculation, orthostatic hypotension, syncope, and dysphagia.
Multiple sclerosis (MS).Urinary incontinence, urgency, and frequency are common urologic findings in MS. In most patients, vision problems and sensory impairment occur early. Other findings include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer.Urinary incontinence usually appears only in the advanced stages of prostate cancer. Urinary frequency and hesitancy, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped, nodular prostate are other common late findings.
Prostatitis (chronic).Urinary incontinence may occur as a result of urethral obstruction from an enlarged prostate. Other findings include urinary frequency and urgency, dysuria, hematuria, bladder distention, persistent urethral discharge, dull perineal pain that may radiate, ejaculatory pain, and decreased libido.
Spinal cord injury.Complete cord transection above the sacral level causes flaccid paralysis of the bladder. Overflow incontinence follows rapid bladder distention. Other findings include paraplegia, sexual dysfunction, sensory loss, muscle atrophy, anhidrosis, and loss of reflexes distal to the injury.
Stroke.With a stroke, urinary incontinence may be transient or permanent. Associated findings reflect the site and extent of the lesion and may include impaired mentation, emotional lability, behavioral changes, altered level of consciousness, and seizures. Headache, vomiting, visual deficits, and decreased visual acuity are possible. Sensorimotor effects include contralateral hemiplegia, dysarthria, dysphagia, ataxia, apraxia, agnosia, aphasia, and unilateral sensory loss.
Urethral stricture.Eventually, overflow incontinence may occur with a urethral stricture. As obstruction increases, urine extravasation may lead to formation of urinomas and urosepsis.
UTI.Besides incontinence, a UTI may produce urinary urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. Bladder spasms or a feeling of warmth during urination may occur.
Other causes
Surgery.Urinary incontinence may occur after prostatectomy as a result of urethral sphincter damage.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary urgency:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Bladder calculus.Bladder irritation can lead to urinary urgency and frequency, dysuria, terminal hematuria, and suprapubic pain from bladder spasms. Pain may be referred to the penis, vulva, lower back, or heel.
Multiple sclerosis (MS).Urinary urgency can occur with or without the frequent UTIs that can accompany MS. Like MS's other variable effects, urinary urgency may wax and wane. Commonly, vision and sensory impairments are the earliest findings. Others include urinary frequency, incontinence, constipation, muscle weakness, paralysis, spasticity, intention tremor, hyperreflexia, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability.
Reiter's syndrome.In Reiter's syndrome, urinary urgency occurs with other symptoms of acute urethritis 1 to 2 weeks after sexual contact. Arthritic and ocular symptoms and skin lesions usually develop within several weeks after sexual contact. These include asymmetrical arthritis of knees, ankles, or metatarsal phalangeal joints; conjunctivitis; and ulcers on the penis, or skin, or in the mouth.
Spinal cord lesion.Urinary urgency can result from incomplete cord transection when voluntary control of sphincter function weakens. Urinary frequency, difficulty initiating and inhibiting a urine stream, and bladder distention and discomfort may also occur. Neuromuscular effects distal to the lesion include weakness, paralysis, hyperreflexia, sensory disturbances, and impotence.
Urethral stricture.Bladder decompensation produces urinary urgency, frequency, and nocturia. Early signs and symptoms include hesitancy, tenesmus, and reduced caliber and force of the urine stream. Eventually, overflow incontinence may occur.
UTI.Urinary urgency is commonly associated with a UTI. Other characteristic urinary changes include frequency, hematuria, dysuria, nocturia, and cloudy urine. Urinary hesitancy may also occur. Associated findings include bladder spasms; costovertebral angle tenderness; suprapubic, low back, or flank pain; urethral discharge in males; fever; chills; malaise; nausea; and vomiting.
Other causes
Treatments.Radiation therapy may irritate and inflame the bladder, causing urinary urgency.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urine cloudiness:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
UTI.Cloudy urine is common with UTI. Other urinary changes include urgency, frequency, hematuria, dysuria, nocturia and, in males, urethral discharge. Urinary hesitancy; bladder spasms; costovertebral angle tenderness; and suprapubic, lower back, or flank pain may occur. Other effects include fever, chills, malaise, nausea, and vomiting.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Cough, barking:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Aspiration of foreign body.Partial obstruction of the upper airway first produces sudden hoarseness, and then a barking cough and inspiratory stridor. Other effects of this life-threatening condition include gagging, tachycardia, dyspnea, decreased breath sounds, wheezing and, possibly, cyanosis.
Epiglottiditis.Epiglottiditis is a life-threatening disorder that has become less common since the use of influenza vaccines. It occurs nocturnally, heralded by a barking cough and a high fever. The child is hoarse, dysphagic, dyspneic, and restless and appears extremely ill and panicky. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia. The child will struggle to get sufficient air as epiglottic edema increases. Epiglottiditis is a true medical emergency.
Laryngotracheobronchitis (acute).Also known as viral croup, laryngotracheobronchitisinitially produces a low to moderate fever, a runny nose, a poor appetite, and an infrequent cough. When the infection descends into the laryngotracheal area, a barking cough, hoarseness, and inspiratory stridor occur.
As respiratory distress progresses, substernal and intercostal retractions occur along with tachycardia and shallow, rapid respirations. Sleeping in a dry room worsens these signs. The patient becomes restless, irritable, pale, and cyanotic.
Spasmodic croup.Acute spasmodic croup usually occurs during sleep with the abrupt onset of a barking cough that awakens the child. Typically, he doesn't have a fever, but may be hoarse, restless, and dyspneic. As his respiratory distress worsens, the child may exhibit sternal and intercostal retractions, nasal flaring, tachycardia, cyanosis, and an anxious, frantic appearance. The signs usually subside within a few hours, but attacks tend to recur.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Cough, nonproductive:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Airway occlusion.Partial occlusion of the upper airway produces a sudden onset of dry, paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia, and decreased breath sounds.
Anthrax (inhalation).Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages, with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.
Aortic aneurysm (thoracic).Aortic aneurysm causes a brassy cough with dyspnea, hoarseness, wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest, stridor and, possibly, paresthesia or neuralgia.
Asthma.Asthma attacks typically occur at night, starting with a nonproductive cough and mild wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.
Atelectasis.As lung tissue deflates, it stimulates cough receptors, causing a nonproductive cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.
Avian influenza.Individuals infected with avian influenza may initially have symptoms of conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches. The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening complications, such as acute respiratory distress and pneumonia.
Bronchitis (chronic).Bronchitis starts with a nonproductive, hacking cough that later becomes productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late stages.
Bronchogenic carcinoma.The earliest indicators of bronchogenic carcinoma can be a chronic, nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.
Common cold.The common cold generally starts with a nonproductive, hacking cough and progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia, nasal congestion, and a sore throat.
Esophageal achalasia.In esophageal achalasia, regurgitation and aspiration produce a dry cough. The patient may also have recurrent pulmonary infections and dysphagia.
Esophageal diverticula.The patient with esophageal diverticula has a nocturnal nonproductive cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and have a gurgling sound. He may also exhibit halitosis and weight loss.
Esophageal occlusion.Esophageal occlusion is marked by immediate nonproductive coughing and gagging, with a sensation of something stuck in the throat. Other findings include neck or chest pain, dysphagia, and the inability to swallow.
Hantavirus pulmonary syndrome.A nonproductive cough is common in patients with Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other findings include a headache, myalgia, fever, nausea, and vomiting.
Hypersensitivity pneumonitis.With hypersensitivity pneumonitis, an acute nonproductive cough, a fever, dyspnea, and malaise usually occur 5 or 6 hours after exposure to an antigen.
Interstitial lung disease.A patient with interstitial lung disease has a nonproductive cough and progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable chest pain, and weight loss.
Laryngeal tumor.A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical lymphadenopathy, stridor, and an earache may occur.
Laryngitis.In its acute form, laryngitis causes a nonproductive cough with localized pain (especially when the patient is swallowing or speaking) as well as fever and malaise. His hoarseness can range from mild to complete loss of voice.
Lung abscess.Lung abscess typically begins with a nonproductive cough, weakness, dyspnea, and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise, fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces large amounts of purulent, foul-smelling and, possibly, bloody sputum.
Pleural effusion.A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub, tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and decreased tactile fremitus.
Pneumonia.Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever, dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring, decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on percussion.
With mycoplasma pneumonia, a nonproductive cough arises 2 or 3 days after the onset of malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest pain. Fever commonly occurs, but the patient doesn't appear seriously ill.
Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise, headache, anorexia, and a low-grade fever.
Pneumothorax.Pneumothorax is a life-threatening disorder that causes a dry cough and signs of respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent breath sounds on the affected side.
Pulmonary edema.Pulmonary edema initially causes a dry cough, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, a ventricular gallop, and anxiety and restlessness. If pulmonary edema is severe, the patient's respirations become more rapid and labored, with diffuse crackles and coughing that produces frothy, bloody sputum.
Pulmonary embolism.A life-threatening pulmonary embolism may suddenly produce a dry cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.
Sarcoidosis.With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss, tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment, difficulty swallowing, and arrhythmias.
Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.
Tracheobronchitis (acute).Initially, tracheobronchitis produces a dry cough that later becomes productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard. Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and, possibly, bronchospasm, with severe wheezing and increased coughing.
Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.
Other causes
Diagnostic tests.Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough receptors and trigger coughing.
Treatments.Irritation of the carina during suctioning or deep endotracheal or tracheal tube placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may stimulate coughing.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Cough, productive:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Actinomycosis.Actinomycosis begins with a cough that produces purulent sputum. A fever, weight loss, fatigue, weakness, dyspnea, night sweats, pleuritic chest pain, and hemoptysis may also occur.
Aspiration pneumonitis.Aspiration pneumonitis causes coughing that produces pink, frothy and, possibly, purulent sputum. The patient also has marked dyspnea, a fever, tachypnea, tachycardia, wheezing, and cyanosis.
Bronchiectasis.The chronic cough of bronchiectasis produces copious, mucopurulent sputum that has characteristic layering (top, frothy; middle, clear; bottom, dense with purulent particles). The patient has halitosis; his sputum may smell foul or sickeningly sweet. Other characteristic findings include hemoptysis, persistent coarse crackles over the affected lung area, occasional wheezing, rhonchi, exertional dyspnea, weight loss, fatigue, malaise, weakness, a recurrent fever, and late-stage finger clubbing.
Bronchitis (chronic).Bronchitis causes a cough that may be nonproductive initially. Eventually, however, it produces mucoid sputum that becomes purulent. Secondary infection can also cause mucopurulent sputum, which may become blood-tinged and foul-smelling. The coughing, which may be paroxysmal during exercise, usually occurs when the patient is recumbent or rises from sleep.
The patient also exhibits prolonged expirations, increased use of accessory muscles for breathing, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea, scattered rhonchi, coarse crackles (which can be precipitated by coughing), and late-stage clubbing.
Chemical pneumonitis.Chemical pneumonitis causes a cough with purulent sputum. It can also cause dyspnea, wheezing, orthopnea, a fever, malaise, and crackles; mucous membrane irritation of the conjunctivae, throat, and nose; laryngitis; or rhinitis. Signs and symptoms may increase for 24 to 48 hours after exposure, then resolve; if severe, however, they may recur 2 to 5 weeks later.
Common cold.When the common cold causes productive coughing, the sputum is mucoid or mucopurulent. Early indications include a dry hacking cough, sneezing, a headache, malaise, fatigue, rhinorrhea (watery to tenacious, mucopurulent secretions), nasal congestion, a sore throat, myalgia, and arthralgia.
Lung abscess (ruptured).The cardinal sign of a ruptured lung abscess is coughing that produces copious amounts of purulent, foul-smelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause diaphoresis, anorexia, clubbing, weight loss, weakness, fatigue, a fever with chills, dyspnea, a headache, malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath sounds. The patient's chest is dull on percussion on the affected side.
Lung cancer.One of the earliest signs of bronchogenic carcinoma is a chronic cough that produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum. Other signs and symptoms include dyspnea, anorexia, fatigue, weight loss, chest pain, a fever, diaphoresis, wheezing, and clubbing.
Nocardiosis.Nocardiosis causes a productive cough (with purulent, thick, tenacious, and possibly blood-tinged sputum) and fever that may last several months. Other findings include night sweats, pleuritic pain, anorexia, malaise, fatigue, weight loss, and diminished or absent breath sounds. The patient's chest is dull on percussion.
North American blastomycosis.North American blastomycosis is a chronic disorder that produces coughing that's dry and hacking or produces bloody or purulent sputum. Other findings include pleuritic chest pain, a fever, chills, anorexia, weight loss, malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or papules), and prostration.
Plague(Yersinia pestis).The pneumonic form of plague may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
Pneumonia.Bacterial pneumonia initially produces a dry cough that becomes productive. Associated signs and symptoms develop suddenly and include shaking chills, a high fever, myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea, tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and rhonchi.
Mycoplasma pneumonia may cause a cough that produces scant blood-flecked sputum. Typically, however, a nonproductive cough starts 2 or 3 days after the onset of malaise, a headache, a fever, and a sore throat. Paroxysmal coughing causes substernal chest pain. Patients may develop crackles, but generally don't appear seriously ill.
Psittacosis.As psittacosis progresses, the characteristic hacking cough, nonproductive at first, may later produce a small amount of mucoid, blood-streaked sputum. The infection may begin abruptly, with chills, a fever, a headache, myalgia, and prostration. Other signs and symptoms include tachypnea, fine crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness, nausea, vomiting, and a faint macular rash. Severe infection may produce stupor, delirium, and coma.
Pulmonary coccidioidomycosis.Pulmonary coccidioidomycosis causes a nonproductive or slightly productive cough with a fever, occasional chills, pleuritic chest pain, a sore throat, a headache, backache, malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and wheezing may be heard. The disease may spread to other areas, causing arthralgia, swelling of the knees and ankles, and erythema nodosum or erythema multiforme.
Pulmonary edema.Severe, pulmonary edema, which is a life-threatening disorder, causes a cough that produces frothy, bloody sputum. Early signs and symptoms include exertional dyspnea; paroxysmal nocturnal dyspnea, followed by orthopnea; and coughing, which may be nonproductive initially. Others include a fever, fatigue, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. As the patient's respirations become increasingly rapid and labored, he develops more diffuse crackles and a productive cough, anxiety, restlessness, worsening tachycardia and, possibly, arrhythmias. His skin becomes cold, clammy, and cyanotic; his blood pressure falls; and his pulse becomes thready.
Pulmonary embolism.Pulmonary embolism is a life-threatening disorder that causes a cough that may be nonproductive or may produce blood-tinged sputum. Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive hemoptysis, chest splinting, leg edema and, with a large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a pleural friction rub, diffuse wheezing, crackles, chest dullness on percussion, decreased breath sounds, and signs of circulatory collapse.
Pulmonary tuberculosis (TB).Pulmonary TB causes a mild to severe productive cough along with some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be scant and mucoid or copious and purulent. Typically, the patient experiences night sweats, easy fatigability, and weight loss. His breath sounds are amphoric. He may have chest dullness on percussion and, after coughing, increased tactile fremitus with crackles.
Silicosis.A productive cough with mucopurulent sputum is the earliest sign of silicosis. The patient also has exertional dyspnea, tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections. Auscultation reveals end-inspiratory, fine crackles at the lung bases.
Tracheobronchitis.Inflammation initially causes a nonproductive cough that later—following the onset of chills, a sore throat, a slight fever, muscle and back pain, and substernal tightness—becomes productive as secretions increase. Sputum is mucoid, mucopurulent, or purulent. The patient typically has rhonchi and wheezes; he may also develop crackles. Severe tracheobronchitis may cause a fever of 101° to 102° F (38.3° to 38.9° C) and bronchospasm.
Other causes
Diagnostic tests.Bronchoscopy and pulmonary function tests (PFTs) may increase productive coughing.
Drugs.Expectorants increase productive coughing. These include ammonium chloride, calcium iodide, guaifenesin, iodinated glycerol, potassium iodide, and terpin hydrate.
Respiratory therapy.Intermittent positive-pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions and cause or increase productive coughing.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Urinary Tract Infection:
Urinary Tract Infection - risk factors
(The 5-Minute Pediatric Consult)
- Sex/Age: Boys most at risk for UTI during first year of life; girls until school age and again in adolescence
- Circumcision status: Uncircumcised males <1 year have 10 times the incidence of UTI compared with circumcised males.
- Abnormal urinary tract: Children with VUR and obstruction are at higher risk for UTI.
- Voiding dysfunction
- Requiring frequent catheterization
- Sexual activity
- Clinical decision rule in girls 2–24 months. Consider testing if 2 or more of following are present:
- Temperature ≥39, fever for ≥2 days, white race, age <1 year, absence of another potential source of fever
Urinary Tract Infection - pathophysiology
- Bacterial invasion of urinary tract from ascending skin or gut flora
- Shorter urethra in females puts them at increased risk
- Poor bladder emptying (neurogenic bladder, obstructive uropathies) facilitates movement of pathogens into upper tract
- In young infants, can be from hematogenous spread
Urinary Tract Infection - etiology
Urinary tract pathogens include:
- Common: Escherichia coli >> Klebsiella spp., Enterococcus, Proteus mirabilis
- Less common: Enterobacter cloacae, group B hemolytic streptococci, Citrobacter, Staphylococcus aureus, Serratia sp. and Staphylococcus saprophyticus (teenage girls)
>>
» READ BOOK EXCERPT ONLINE »
Source: The 5-Minute Pediatric Consult, 2008
Urinary Tract Infections:
Etiology
(Pediatric Infectious Disease)
Pediatric urinary tract infection begins with colonization of the periurethral
area with gastrointestinal bacteria. These bacteria may then ascend into the
bladder, kidneys, or both. A variety of virulence factors may promote infection
with certain bacterial isolates.
Escherichia coli organisms, a primary cause of urinary tract infection, have a variety of
adhesive molecules that facilitate binding to uroepithelial cells. These
“pili” function as ladders that enable the bacteria to ascend from the periurethral
area into the urinary tract.
Host factors may also play a role in the development of complicated urinary
tract infection. Ascension of bacteria from the bladder into the renal
parenchyma may be facilitated by vesicoureteral reflux (VUR). VUR is a
congenital condition resulting from a defect in the ureterovesical junction.
This defect affects closure of the ureter, which then allows retrograde flow of
urine from the bladder into the kidneys. Infection with
E. coli accounts for most urinary tract infections. Less common pathogens include
enterococcus and other enterics such as
Proteus species.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Infectious Disease, 2004
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