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Diagnosis of Urinary tract infections (child)

Diagnostic Test list for Urinary tract infections (child):

The list of medical tests mentioned in various sources as used in the diagnosis of Urinary tract infections (child) includes:

Urinary tract infections (child) Diagnosis: Book Excerpts

Diagnostic Tests for Urinary tract infections (child): Online Medical Books

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COUGH: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it acute or chronic? Acute onset of a cough would suggest an acute URI, viral pneumonia, or bronchopneumonia. A chronic cough is more suggestive of pneumoconiosis, chronic bronchitis, emphysema, bronchiectasis, tuberculosis, carcinoma of the lung, or bronchial asthma.
  2. Is there exposure to toxic fumes? The most common toxic fume is cigarette smoke. However, if one asks the patient's occupation one might find that he is a miner and therefore pneumoconiosis comes to mind. One might find that he is an aircraft maker or shipbuilder, in which case berylliosis and asbestosis would come to mind, or that he is a farmer and, therefore, farmer's lung would come to mind.
  3. Is there significant sputum production? If so, what is the nature of the sputum? Purulent sputum would suggest a pneumonia, abscess, tuberculosis, or bronchiectasis; bloody sputum would suggest carcinoma of the lung, tuberculosis, and bronchiectasis; mucoid sputum would suggest asthma. If the sputum is foamy, one would consider congestive heart failure, mitral stenosis, and inhalation of poison gas.
  4. Is there fever? If there is fever associated with the cough, obviously one would suspect an infectious process to be present. This could be viral or bacterial. Most likely the patient has bronchopneumonia, but the possibility of an abscess or pulmonary infarct would still have to be entertained.
  5. What other symptoms and signs are associated with the cough? The first thing to be considered would be dyspnea. In acute cases dyspnea would be a sign of congestive heart failure, pulmonary embolism and, of course, advancing pneumonia. In chronic cases dyspnea would be a sign of emphysema, chronic pulmonary fibrosis, and chronic congestive heart failure. Wheezing would be a sign of asthma or congestive heart failure, but of course it is also found in pulmonary emphysema. Cardiomegaly would suggest congestive heart failure and if there is an associated murmur, that makes congestive heart failure even more likely. If there is hepatosplenomegaly, one would suspect a systemic disease involving the lungs such as periarteritis nodosa or other collagen diseases.
  6. Is the patient taking drugs? Angiotensin-converting enzyme (ACE) inhibitors such as captopril are well known to cause cough.

DIAGNOSTIC WORKUP

If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.

Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H 2 antagonist may also be diagnostic.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

DYSURIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there fever? A significant fever would suggest either pyelonephritis, particularly in females, or acute prostatitis in males.
  2. Is the urine grossly bloody or are there a significant number of red cells on microscopic examination? Grossly bloody urine in a young female should suggest acute cystitis, particularly if she has just returned from a honeymoon. In older patients it may indicate bladder carcinoma, but generally these patients have blood in their urine before they develop dysuria. Really significant blood in the urine may also indicate schistosomiasis or tuberculous cystitis. Dysuria and hematuria can occur in renal or vesicular calculi as well.
  3. Is there a urethral or vaginal discharge? If either of these signs is present, one must consider that the patient may have gonorrhea until proven otherwise. Repeated negative smears and cultures for gonococcus should suggest that the patient may have female urethral syndrome or nonspecific urethritis due to chlamydia.
  4. Are there systemic symptoms? If there are systemic symptoms, one must consider the possibility of Reiter's syndrome or collagen disease. One should not forget that systemic symptoms of arthritis and rash may also be present in gonorrhea.
  5. Is the pain very severe? Severe pain, particularly a need to stay close to the restroom so one can empty one's bladder, may indicate tabes dorsalis, although this condition is rarely seen today.

DIAGNOSTIC WORKUP

Obviously, a urinalysis and Gram stain of the unspun urine should be done in all cases. If this is positive, treatment can be initiated. Urine cultures are only necessary for resistant or repeated episodes. I also recommend a urethral smear and a vaginal smear and culture if sufficient material can be obtained. This may mean massaging the prostate for an adequate specimen. Even four white cells per high-powered field on a urethral smear probably indicates urethritis. Cultures for both gonorrhea and chlamydia should be done. In persistent cases of dysuria, an intravenous pyelogram and a cystoscopy must be done. A urologist needs to be consulted before ordering these tests. Blood cultures should be done in cases of acute pyelonephritis. Cultures for anaerobic bacilli and tuberculosis may be necessary in persistent pyuria. It should go without saying that a rectal and vaginal examination should be done in all cases. However, this is frequently neglected.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

POLYURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it transient? Migraine, asthma, and drugs such as diuretics may produce transient polyuria.
  2. Is it massive? Massive polyuria is usually due to pituitary or nephrogenic diabetes insipidus and psychogenic polydipsia. It may also be due to diabetes mellitus.
  3. Is there polyphagia and polydipsia? The presence of polyphagia and polydipsia suggests the possibility of diabetes mellitus and hyperthyroidism.
  4. Is the polyuria mild? The presence of a mild polyuria suggests chronic nephritis, renal tubular acidosis, hyperparathyroidism, Fanconi's syndrome, and mild diabetes mellitus.
  5. Is there glycosuria? The presence of glycosuria suggests diabetes mellitus, hyperthyroidism, and Fanconi's syndrome.

DIAGNOSTIC WORKUP

Routine tests include a CBC, sedimentation rate, urinalysis, urine culture and colony count, chemistry panel, thyroid panel, and x-rays of the skull and long bones. The 24-hr intake and output should be measured. A serum and urine osmolality will be helpful, as would a spot urine sodium.

If pituitary diabetes insipidus is suspected, a CT scan of the brain and tests for pituitary hormones should be done. The intake and output before and after Pitressin® may be measured.

If renal disease is suspected, the urinary sediment should be examined microscopically and renal biopsy may be necessary. An endocrinologist and nephrologist should be consulted before undertaking expensive diagnostic tests.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PROTEINURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there significant numbers of white blood cells (WBCs) in the urine? This would suggest a UTI. If there are white cell casts or clumps, the infection may be a pyelonephritis. A urine culture and colony count should be ordered. Sterile urine with persistent proteinuria and pyuria may be seen in toxic nephritis.
  2. Are there increased RBCs in the urine? This would suggest glomerulonephritis, collagen disease, polycystic kidney, tuberculosis, renal calculus, trauma, or neoplasm. The presence of red cell casts would make glomerulonephritis or collagen disease more likely.
  3. Is glucose present in the urine? This would point to diabetic nephritis or nephrosis.
  4. If none of the above associated findings are present, one should look for hypertension, toxemia of pregnancy, fever, cardiac disease, poisoning, orthostatic proteinuria, multiple myeloma, or amyloidosis.

DIAGNOSTIC WORKUP

When faced with a report of protein in the urine, the first thing to do is look at the urine under the microscope. If there are significant numbers of bacteria and WBCs, one has only to order a urine culture and colony count and begin therapy. Recurrent UTIs warrant an IVP and a referral to a urologist, especially in males. If no infection is found, a more thorough workup is warranted, including CBC, chemistry panel, serum protein electrophoresis, ANA, sedimentation rate, urine for Bence-Jones protein, Addis count, ASO titer, IVP, and CT scan of the abdomen. A urologist may need to be consulted for cystoscopy and retrograde pyelography. A nephrologist may need to be consulted for renal biopsy and further evaluation.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PYURIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there significant RBCs in the urine? If so, one should consider glomerulonephritis, collagen disease, tuberculosis, neoplasm, trauma, renal calculus, and polycystic kidney disease. If not, the most likely etiology is a UTI.
  2. Are there WBC casts in the urine? This would make pyelonephritis or interstitial nephritis more likely.
  3. Are there RBC casts in the urine? This would help differentiate glomerulonephritis and collagen diseases from the other conditions associated with hematuria.

DIAGNOSTIC WORKUP

First, look at the urinary sediment under a microscope. Further workup should include a urine culture and colony count, AFB smear and culture, CBC, sedimentation rate, ANA test, chemistry panel, serum protein electrophoresis, IVP, and a urology consultation. A urologist may do cystoscopy and retrograde pyelography. He may order a CT scan of the abdomen to rule out renal carcinomas and other kidney disease. A nephrologist may need to be consulted in difficult cases. A urologist should be consulted in all cases of recurrent or persistent pyuria.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ANURIA OR OLIGURIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Has the patient been on any drugs? Sulfonamides are notorious for causing renal failure, but one must also consider amphotericin B, gold compounds that might be administered in arthritis, and lead and other drugs or heavy metals.
  2. What is the blood pressure? If there is hypertension and anuria, one should consider acute or chronic glomerulonephritis, polycystic kidneys, and acute tubular necrosis. If there is a low blood pressure, one should consider prerenal causes of anuria such as dehydration, blood loss, the acute abdomen, and other causes of shock.
  3. Is there cardiomegaly or chest pain? If there is an enlarged heart, one should consider congestive heart failure. If there is chest pain, one should consider myocardial infarction or pulmonary infarction. If there is chest or abdominal pain with hypertension, then one should consider dissecting aneurysm.
  4. Is there enlargement of the kidneys? Enlargement of both kidneys should suggest bilateral hydronephrosis or polycystic kidneys. Unilateral enlargement of the kidneys is not usually associated with anuria.
  5. Is there bladder enlargement? Enlarged bladder would make one think of bladder neck obstructions due to prostatic hypertrophy or carcinoma or a urethral stricture. Occasionally, what is thought to be an enlarged bladder is actually a pelvic mass that is obstructing the ureter.
  6. Is there hematuria? Hematuria would suggest glomerulonephritis, acute tubular necrosis, intravascular hemolysis, and nephrolithiasis.
  7. What has been the patient's recent intake of fluid? Dehydration is a frequent cause of oliguria and anuria.

DIAGNOSTIC WORKUP

The first thing to determine is whether the patient really has anuria or oliguria. A Foley catheter should be passed and attached to drainage to determine the urine output. If there is obstructive uropathy due to bladder neck obstruction, obviously this will determine the diagnosis, as there will be a large volume of urine and it should be taken off gradually. Then studies of obstructive uropathy can be done, including cystoscopy and retrograde pyelography. If the obstructive uropathy is due to obstruction of the ureter, renal ultrasonography can be reliable in detecting the dilated calyces or dilated ureter.

If the patient presents with anuria and hypotension, the most important thing is to reestablish the blood pressure. If the anuria does not cease at this point, high-dose furosemide or a mannitol infusion can be started. Meanwhile, a CBC, chemistry panel, urinalysis, spot urine sodium, serum protein electrophoresis, an ANA assay, an EKG, and chest x-ray should be done. A flat plate of the abdomen should give an idea of the kidney size. The clinician should examine the urinary sediment himself, and this will identify cases of acute glomerulonephritis, lupus erythematosus, and acute tubular necrosis with considerable accuracy. The blood urea nitrogen (BUN) and creatinine ratio are helpful in distinguishing pre-renal from renal azotemia.

If intravascular hemolysis is suspected, serum haptoglobins and serum hemoglobin should be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. Renal angiography and aortography should be done in cases of suspected dissecting aneurysm or bilateral renal artery stenosis. Abdominal ultrasound will also be helpful in diagnosing polycystic kidneys and pelvic masses that may be obstructing the ureter. A CT scan may be necessary as well.

In difficult cases, a renal biopsy may be necessary to diagnose the various collagen diseases and the various forms of glomerulonephritis. Referral to a nephrologist would be best at this point.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Dysuria: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Lower urinary tract etiologies (male)
    –Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
    –Acute prostatitis
    –Benign prostatic hypertrophy
    –Epididymitis/urethritis: Chlamydia, gonorrhea, E. coli, staphylococcus aureus
    –External infections (e.g., herpes)
    –Allergic reaction to contraceptives, soaps, lotions
    –Malignancy (urethral or bladder cancer)
    –Urethral strictures
  • Lower urinary tract etiologies (female)
    –Infectious cystitis: E. coli (#1 cause), Staphylococcus saprophyticus, Proteus, Klebsiella, Enterococcus
    –Acute urethritis: Chlamydia, gonorrhea
    –Vaginitis: Candida, herpes
    –Atrophic vaginitis
    –Allergic reaction to contraceptives, soaps, lotions
    –Malignancy: Urethral cancer, bladder cancer
    –Urethral strictures
    –Vaginitis (Trichomonas, bacterial vaginosis)
    • Upper urinary tract etiologies
      –Pyelonephritis: Fever, chills, nausea, vomiting, and CVA tenderness
      –Urolithiasis: Acute onset of dysuria with associated flank pain, with or without hematuria
  • Reiter's syndrome
    –Genital ulcers, conjunctivitis, and arthritis
  • Noninfectious cystitis (e.g., drugs, radiation, granulomatous, allergic)
  • Behçet syndrome
    –Oral and genital ulcers, arthritis, and uveitis
  • Trauma
  • Rectal fissure
  • Psychogenic (e.g., conversion disorder)

    • Workup and Diagnosis

    • History and physical examination
    • Male genital exam with gonorrhea/chlamydia test, culture, Gram stain
      –Tender, boggy, swollen prostate suggests prostatitis (avoid prostatic massage, because of risk of bacteremia)
      –Tender epididymitis and testicles suggest infection
      –Generally enlarged prostate associated with nocturia and increasing frequency suggests BPH
    • Female genital exam with KOH prep, wet mount, Gram stain, and DNA tests/culture as indicated
      –Thin, papery vaginal tissue suggests atrophic vaginitis
      –Candida discharge is thick, cheesy, and white; pruritic
      –Chlamydia discharge is scant, watery and gradual onset
      –Gonorrhea discharge is profuse, yellow-green with abrupt onset, intracellular gram-negative diplococci
      –Bacterial vaginosis discharge is pruritic, with clue cells on wet mount and a fishy odor with KOH (whiff test)
      –Trichomonas discharge is frothy, grey-green, with pruritis and mobile organisms on wet mount
      • Urinalysis should be done in all patients
        –Hematuria suggests urolithiasis, pyelonephritis, or cystitis; painless hematuria suggests bladder cancer
        –Positive nitrites, leukocyte esterase, or WBCs with suprapubic tenderness suggests uncomplicated cystitis
      • Urine culture is indicated if positive urinalysis and in pregnant women, diabetic or immunocompromised patients, or males with urethral discharge

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Polyuria: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Diuretic use
    • Primary polydipsia
      –Usually in middle-aged, anxious women
      –Psychiatric illnesses due to increased water intake (e.g. psychogenic polydipsia)
      –May be due to hypothalamic lesions in the thirst centers (e.g., sarcoidosis)
    • Chronic lithium use
      –20% of patients develop polydipsia
    • Central diabetes insipidus
      –Due to decreased output of antidiuretic hormone
      –May be idiopathic, familial, autoimmune, or due to head trauma, infiltrative diseases (e.g., sarcoidosis, granulomas, Langerhans cell histiocytosis), pituitary tumors (intrasellar, suprasellar), or ischemic or hypoxic encephalopathy
    • Nephrogenic diabetes insipidus
      –Due to decreased response of the kidneys to antidiuretic hormone
      –May be idiopathic, familial, or due to drugs (e.g., colchicine, fluoride, phenothiazine), chronic renal disease, hypercalcemia, hypokalemia, sickle cell disease
    • Uncontrolled diabetes mellitus
      –Patients have polydipsia and subsequent polyuria secondary to high sugar levels

    Workup and Diagnosis

    • Complete history and physical exam with corroboration from caretakers and family if available
    • Initial laboratory studies include serum and urine fasting glucose, creatinine, electrolytes, osmolality, and serum BUN
    • Water deprivation test
      –Give no fluids for 12–18 hours and measure body weight, plasma and urine osmolarity, blood pressure, and urine specific gravity every 2 hours
      –Stop test if severe dehydration or drop in BP occurs (indicates diabetes insipidus likely)
      –A normal response is a drop in urine output to 0.5 mL/min, and urine osmolarity >plasma osmolarity
      –Maintenance of dilute urine with specific gravity <1.005 indicates diabetes insipidus (central or nephrogenic)
      –Continue test until plateau phase (hourly increase UOP <30 mOsm/kg for 3 consecutive hours)
      –Then give 5 mg ADH SQ and measure urine osmolarity 1 hour later
    • Measure ADH and osmolarity levels during water test
      –Nephrogenic diabetes insipidus: Normal or slightly increased ADH; urine osmolality increases <50% after ADH given
      –Complete central diabetes insipidus: Decreased levels of ADH; urine osmolarity >plasma osmolarity
      –Primary polydipsia: Serum and urine osmolarity are decreased before the test and increase during the water deprivation test
    >>>

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Cough - Nonproductive: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Smoker's cough
    • Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
      –Most common cause of chronic cough in nonsmokers
    • GERD
      –Second most common cause of chronic cough in nonsmokers
    • Asthma/reactive airway disease
      –Classic triad of chronic cough, dyspnea, and wheezing
  • ACE inhibitor use
  • Acute bronchitis
    –Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
    –Postviral bronchitis may last beyond 6 weeks
  • Pneumonia
    –“Typical” pneumonia (e.g., Streptococcus pneumoniae, Haemophilus influenzae, or influenza/parainfluenza viruses) is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
    –“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia) is characterized by more gradual onset, dry cough, headache, fatigue, and minimal lung signs
  • Aspirated foreign body
    –Abrupt onset of unilateral wheezing or stridor, cough, decreased breath sounds
    –Leading cause of home accidental death in children younger than 6 (boys >girls)
    • Lung cancer
      –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)
  • COPD (emphysematous variant)
  • Sarcoidosis
    • Cryptogenic organizing pneumonia
      –Most commonly occurs following viral infection or exposure
  • Congestive heart failure
  • Filarial disease
  • Aspiration

    • Workup and Diagnosis

    • Complete history and physical examination
      –Note acute (<3 weeks) versus chronic or recurrent
    • Initial tests may include CBC, pulse oximetery, ESR, peak flow measurements, PPD, and eosinophil count
    • Chest X-ray and/or CT if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
    • Consider blood and sputum cultures
    • Initial empiric treatment of postnasal drip (antihistamine, decongestant, nasal steroids), asthma (trial of bronchodilators or a methacholine challenge test), and/or GERD (proton pump inhibitor) may be advisable
    • If imaging is normal and empiric treatment for GERD does not resolve symptoms, proceed with upper GI endoscopy or esophageal pH monitoring
    • Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
    • Consider bronchoscopy to identify subtle pulmonary causes
    • Consider cardiac workup if pulmonary and GI evaluations are negative
    >

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Cough - Productive: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
      –Most common cause of chronic cough in nonsmokers
    • Acute bronchitis
      –Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
      –Bacteria are much less common (e.g., Streptococcus pneumoniae, Mycoplasma, Haemophilus influenzae)
    • Pneumonia
      –May be community-acquired, hospital-acquired, or due to aspiration
      –“Typical” pneumonia (e.g., S. pneumoniae, H. influenzae, influenza virus) has acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and productive cough
      –“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia, Pneumocystis carinii) has more gradual onset, dry cough, headache, fatigue
    • Smoker's cough
      • Lung cancer
        –90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)
      • Asthma with secondary infection
      • COPD (chronic bronchitis component)
      • Congestive heart failure
        –Associated with “frothy” sputum
      • Tuberculosis

      Workup and Diagnosis

      • Complete history and physical examination
        –Note acute (<3 weeks) versus chronic or recurrent
      • Initial tests may include CBC, pulse oximetry, ESR, peak flow measurements, PPD, chest X-ray, blood cultures, sputum Gram stain and culture, and acid-fast stain for tuberculosis
      • Pulmonary function tests with or without methacholine challenge
      • Chest CT and/or sputum cytology if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
      • Initial empiric treatment for postnasal drip (antihistamine, decongestant, nasal steroids)
      • Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
      • Consider bronchoscopy with possible bronchoalveolar lavage and/or biopsy
      >

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Dysuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urinary tract infection (UTI)
      –Common cause of dysuria in children
      –Common pathogens: bacteria including E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa and other gram negatives
    • Sexually transmitted disease (STD)
      –Gonorrhea, Chlamydia, Trichomonas
      –Very common in sexually active patients
      –More common in girls
      • Bacterial vaginosis
        –Gardnerella or Mobiluncus spp, may be sexually or nonsexually transmitted
    • Candidal vaginitis
      –Common after antibiotic treatment
    • Local urethral irritation
      –Pinworms
      –Irritative dermatitis (e.g., bubble bath)
      –Diarrhea
    • Hemorrhagic cystitis
      –Typically viral in origin
      –Sudden in onset
    • Macroscopic blood in the urine from any cause, causing urethral irritation
    • Periurethral herpes simplex
    • Periurethral varicella
    • Hypercalciuria
      –Dysuria and urinary frequency
    • Kidney stone (within the urethra)
    • Renal tuberculosis (rare)
      –Typically asymptomatic
      –Sterile pyuria
    • Prostatitis (uncommon)
      –Can affect adolescent boys
      –Gonorrhea is the most common cause
    • Trauma to the perineum
      –Sexual abuse
      –Masturbation
    • Meatal ulceration
      –In boys, may occur from contact with diapers
    • Pelvic abscess, including appendicitis
    • Drugs
      –Amitriptyline hydrochloride (antidepressant)
    • Reiter disease
      –Uncommon in children
      –Triad of arthritis, urethritis, and conjunctivitis

    Workup and Diagnosis

    • History
      –UTI, STD, sexual activity, recent antibiotic exposure
      –Instrumentation/irritation (urinary catheters, bubble baths, creams, masturbation)
      –Fever, abdominal pain, flank pain, vaginal discharge
      –Enuresis (especially new-onset), macroscopic hematuria, frequency, urgency
      –Family history of kidney stones (increased likelihood of hypercalciuria)
      • Physical exam
        –Fever, CVA tenderness
        –Exam of the urethra/periurethral area for irritation
        –Pelvic exam (if done) for cervical motion tenderness, cervicitis, or vaginal discharge
      • Labs
        –Urinalysis, urine culture
        –STD screening if sexually active
        –Urine spot calcium and creatinine if evidence of microscopic hematuria
    • Additional studies based on clinical situation
      –Pelvic ultrasound if PID suspected
      –Renal ultrasound/voiding cystourethrogram if history of previous UTI (in girls <7 and boys of any age), or if macroscopic hematuria is present
      –High-resolution CT without contrast (kidney stones)
      –24-hour urine calcium (hypercalciuria, kidney stones)
    >

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Proteinuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

      • Transient proteinuria
        –With fever, dehydration, exercise, seizures, cold exposure, or stress
        –Rarely >2+ on dipstick
        –Usually remits within 1–2 weeks
    • Orthostatic (postural) proteinuria
      –Occurs mostly in adolescence
      –First morning U/A is negative for protein
    • Primary glomerular disease
      –MCNS: Most common cause of nephrotic syndrome (NS) in younger children, usually presents in ages 2–6, more common in boys; etiology possibly immune-mediated, typically responds to corticosteroids
      –Mesangial proliferative GN: Intermediate lesion between MCNS and FSGS
      –FSGS: Progressive disease of glomerular scarring, more common in blacks and adolescents, presents as NS or asymptomatic proteinuria, frequently resistant to corticosteroid therapy
      –Membranous nephropathy
      –Any primary GN (e.g., APSGN) can present with hematuria and proteinuria
    • Systemic lupus erythematosus nephritis
    • Henoch-Schönlein purpura (HSP)
    • Wegener granulomatosis
      • Tubulointerstitial disease: Proteinuria is less than with primary glomerular diseases
        –Reflux nephropathy
        –Renal dysplasia
        –Interstitial nephritis (especially NSAIDs)
        –Polycystic kidney disease
      • Infectious disease
        –Bacterial (e.g., poststrep, shunt nephritis, leprosy, syphilis, infective endocarditis)
        –Viral (e.g., HBV, CMV, EBV, VZV, HIV)
        –Protozoal (e.g., malaria, toxoplasmosis)
        –Parasitic (e.g., schistosomiasis, filariasis)
    • Neoplasm (e.g., lymphoma, leukemia, Wilms tumor, pheochromocytoma)
    • Alport syndrome
    • Fabry disease
    • Nail-patella syndrome
    • Medications (e.g. gold, mercurials)
    • Constrictive pericarditis

    Workup and Diagnosis

    • History
      –Renal disease
      –Recurrent UTIs
      –HIV infection
      –Edema (periorbital or extremity)
      –Fatigue
      –Weight loss or gain
      –Pallor (seen with anemia of chronic disease)
      –Gross hematuria
      –“Foamy” urine
    • Physical exam
      –Blood pressure, growth parameters
      –Edema (periorbital or extremity), ascites
      –Rashes or joint abnormalities
    • Labs
      –Serum chemistries including albumin and triglycerides
      –U/A, 24-hour urine collection for protein
      –C3, C4
      • If asymptomatic proteinuria, obtain “first morning” void, preferably prior to ambulation, to rule out orthostatic proteinuria before performing extensive lab workup
        –If U/A is negative for protein, additional diagnostic testing is not necessary
    • Additional tests as indicated by the history
      –ANCA, ANA, HIV
    • Renal ultrasound

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    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Pyuria: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urinary tract infection
    • Asymptomatic bacteriuria
      –Relatively common in school-age girls
      –Urine cultures are repeatedly positive
      –Patients remain asymptomatic
      • Sexually transmitted disease (STD)
        –Gonorrhea, Chlamydia, Trichomonas
        –Bacterial vaginitis (can be nonsexually transmitted)
    • Other causes of vaginal discharge/perineal irritation (e.g., candidal vaginitis)
      • Acute interstitial nephritis
        –“Allergic” tubulointerstitial process
        –Occurs 7–14 days after exposure to inciting agent (e.g., antibiotics or NSAIDs)
        –May have polyuria, fever, and rash, and elevated serum creatinine of unclear etiology
        –Urinalysis is otherwise unremarkable
    • Inherited cystic diseases
      –PKD: Occurs in both autosomal dominant and autosomal recessive forms
      –Juvenile nephronophthisis: Rare cause of inherited chronic tubulointerstitial nephritis, steady progression to kidney failure in the first two decades of life, autosomal recessive inheritance
      • Appendicitis
        –May present with symptoms suggestive of acute pyelonephritis (fever, flank or abdominal pain)
        –Urine culture is negative
        –Symptoms are progressive
      • Renal tuberculosis
        –Routine urine culture negative
      • Gastroenteritis (typically viral)
      • Lupus nephritis
      • Alport syndrome
      • Nail-patella syndrome
      • Urethritis
      • Kawasaki disease
        –Most common vasculitis of childhood
        –Characterized by high fever, irritability, mucous membrane changes, edema of the hands and feet, lymphadenopathy
        –Coronary vasculitis and aneurysms may result
        –Treated with aspirin and IVIG

    Workup and Diagnosis

      • History
        –Previous UTI or positive urine culture
        –Unprotected sexual activity, previous STD
        –Recent antibiotic or other medication exposure
        –Poor growth (seen in chronic kidney disease)
        –Dysuria, urgency, frequency, fever, flank pain
        –Polyuria, polydipsia
        –Abdominal pain (particularly right lower quadrant)
        –Family history of polycystic kidney disease or other inherited kidney disease
    • Physical exam
      –Temperature, BP, height, and weight
      –Rashes
      –Pelvic exam (if patient sexually active)
      –Exam of the external genitalia
      –Abdominal masses
      –Costovertebral angle tenderness
    • Labs
    • Urinalysis (including microscopy), urine culture
      –STD screen if sexually active: GC culture, Chlamydia DNA probe or ligase chain test, wet prep for Trichomonas
      –Chemistry panel to screen for renal disease
      • Additional studies depend on the clinical situation
        –Abdominal CT scan or ultrasound for appendicitis
        –Renal ultrasound if inherited cystic diseases are suspected

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    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Cough – Acute: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Upper airway disease
      –URI or common cold accounts for much pediatric coughing (influenza, parainfluenza, rhinovirus)
      –Chronic sinusitis, tonsillitis, laryngitis, and croup are other common infections
      –Allergic disease
      –Vocal cord dysfunction (VCD)
    • Lower airway disease
      –Asthma is inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs (the most common triggers for asthma are viral disease, irritants such as ETS, allergic disease, and gastroesophageal reflux)
      –Infectious diseases: Bronchiolitis, caused by RSV in babies, causes cough from inflammatory changes and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure; other viral lower airway diseases include adenovirus, influenza, and parainfluenza
      –Foreign body aspiration
      –Chronic diseases (e.g., cystic fibrosis and bronchiectasis) and structural abnormalities (e.g., PCD, TEF, or cleft, rings, and slings) may present with intermittent rather than chronic cough
    • Parenchymal and pleural disease
      –Infectious diseases account almost exclusively for all parenchymal and pleural causes of cough (i.e., pneumonia and empyema)
      –Usual infectious agents include bacterial disease (e.g., streptococcal, staphylococcal) and atypical pneumonias (e.g., Mycoplasma pneumoniae), TB
      –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger cough

      • Workup and Diagnosis

      • History
        –What started it? History (e.g., infection or FB aspiration) may suggest a mechanism
        –What makes it worse? Activity leading to cough may suggest asthma or structural disease; seasonal onset suggests allergic disease; night cough suggests GER
        –Is the cough productive? Infection is the primary cause of sputum production; also consider asthma, bronchiectasis, smoking, or CF
        • Physical exam
          –Loud, “brassy,” vibrato, honking quality suggests tracheomalacia
          –High-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis)
          –Violent paroxysms with an inspiratory whoop suggests pertussis syndrome
          –A productive, “wet” cough suggests bronchitis or pneumonia
          –A wheezy, “tight” cough suggests asthma
        • Studies
          –CXR may demonstrate an atypical pneumonia
          –Pulmonary function tests to diagnose asthma or large airway obstruction
          –Bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
          –V/Q scan may diagnose a pulmonary embolus (rare)
      • Exercise testing may provoke symptoms of exercise-induced asthma or VCD

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    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Cough – Chronic: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Lower airway disease
      –Asthma
           –Inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs
      –The most common triggers for asthma are viral disease, irritants (e.g., ETS), allergic disease, and GER
      –Airway infections: Bronchiolitis, caused by RSV in babies, may cause chronic cough from persistent inflammatory change and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure
      –Foreign body: Associated with endobronchial infection and damage
      –Cystic fibrosis: The most common life-threatening inherited illness of whites, is associated with production of chronically infected sputum
      –Bronchiectasis: Chronic infection and damage to the airway; may be secondary to another disease (e.g., TB or CF)
      –Structural abnormalities: PCD, TEF, or cleft, rings, slings
      • Upper airway disease
        –Infectious diseases: Chronic sinusitis, tonsillitis, laryngitis, including that secondary to GER (although acute disorders, the inflammation from URI may be associated with a chronic cough if frequent enough)
    • Parenchymal and pleural disease
      –Infectious disease accounts almost exclusively for all parenchymal and pleural causes of cough (e.g., pneumonia and empyema)
      • CNS causes
        –CNS causes of cough include “habit cough” (or psychogenic cough), Tourette disease associated “cough tic” or throat clearing, VCD
        –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger chronic cough

      Workup and Diagnosis

      • History
        –Cough lasting longer than 2–6 weeks suggests either a predisposing factor (e.g., bronchomalacia) or an ongoing trigger (e.g., asthma)
        –An acute lung or airway injury (i.e., infection or FB) suggests a mechanism for chronic cough
        –An insidious onset is more consistent with a chronic underlying condition (i.e., CF, TB, GER)
        –Seasonal change suggests allergic disease
        –Night cough suggests GER
        –A positive response to asthma therapy suggests asthma
        –Antibiotic responsiveness suggests chronic infection (i.e., CF, bronchiectasis, sinusitis)
        –Distractability suggests habit cough, as may a lack of coughing while asleep
        –Is the cough productive? Culture sputum and consider asthma, bronchiectasis, smoking, or CF
      • Physical exam: Loud, “brassy,” vibrato, honking quality suggests tracheomalacia; high-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis); violent paroxysms with an inspiratory whoop suggest pertussis syndrome
      • Studies: Chest films often not diagnostic; PFT to diagnose asthma or large airway obstruction; bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
      • Exercise testing may provoke symptoms of EIA or VCD

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    Source: In A Page: Pediatric Signs and Symptoms, 2007

    COUGH: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. An allergic history (e.g., hay fever) is important. Careful exclusion of cardiovascular disease should be done, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

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    Source: Differential Diagnosis in Primary Care, 2007

    DYSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes a urinalysis, urine cultures, smear and culture of any discharge, an intravenous pyelogram, voiding cystogram and cystoscopy, and cystometric examination. In females with “negative” cultures, Chlamydia urethritis must be considered and treated. In males with negative cultures, prostatic examination, massage, and evaluation of discharge are done.

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    Source: Differential Diagnosis in Primary Care, 2007

    POLYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of polyuria depends largely on the association of other symptoms. Polyuria, polyphagia, and polydipsia suggest diabetes mellitus and hyperthyroidism. Polyuria with only polydipsia suggests psychogenic or idiopathic diabetes insipidus; the Hickey–Hare test will differentiate the two. Polyuria with polydipsia and weakness but with no significant weight loss suggests hypercalcemia and possible hyperparathyroidism. Chronic nephritis will be diagnosed by examination of the urine sediment and a specific gravity that remains at 1.010. Nephrogenic diabetes insipidus can be differentiated from neurogenic diabetes insipidus by the inability of the kidney to respond to a pitressin injection.

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    Source: Differential Diagnosis in Primary Care, 2007

    PROTEINURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The first step is to determine whether the proteinuria is caused by infection. A urinalysis for WBCs and examination of a fresh drop of unspun urine under the microscope for the bacteria are the fastest ways of determining this. The urine can also be cultured. Next, determine if there are red cells in the urine. This would indicate a more serious cause for the proteinuria such as collagen disease, stone, glomerulonephritis, or neoplasm and prompts the need for an IVP, cystoscopy, and urology consult.

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    Source: Differential Diagnosis in Primary Care, 2007

    PYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    How does one track down the cause of pyuria? First, it must be determined that the cloudy urine is really pyuria. Amorphous phosphates and other inert material will disappear on treating the urine with dilute acetic acid. Then, just as for other nonbloody discharges, one must do a smear and culture for the offending organism; an examination of the urine, especially the unspun specimen, is axiomatic. If one finds clumps of leukocytes, renal gitter cells, or WBC casts, the infection almost certainly comes from the kidney. Motile bacteria in an unspun specimen examined under high-power microscopy and a colony count of over 100,000 ÷mL signify infection. A three-glass test may be helpful in localizing the site of origin of the pyuria. Anaerobic cultures and cultures for Chlamydia may be needed. Look for eosinophils on a Wright stain of the urine if toxic nephritis is suspected.

    Vaginal examination and culture may disclose a source for the infection. In the male, one episode of pyuria should be sufficient indication for an IVP; a female should have one after her second episode, especially if no cause can be found on physical examination. Cystoscopy and a voiding cystogram are often indicated at this time.

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    Source: Differential Diagnosis in Primary Care, 2007

    ANURIA AND OLIGURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis).

    The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine and if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography once the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also.

    The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal Azotemia, the BUN: creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN:creatinine ratio will be 10:1 or less.

    Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his/her anuria and a urologist should be consulted.

    Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, serum haptoglobins should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer or lupus erythematosus (LE) cell prep. A renal biopsy may also be necessary in these disorders and many others.

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    Source: Differential Diagnosis in Primary Care, 2007

    INCONTINENCE, URINARY: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.

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    Source: Differential Diagnosis in Primary Care, 2007

    Oliguria: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Polyuria: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate his fluid status first. Take his vital signs, noting an increased body temperature, tachycardia, and orthostatic hypotension (a ≥10 mm Hg decrease in systolic blood pressure upon standing and a ≥10 beats/minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you’ll need to infuse replacement fluids.

    If the patient doesn’t display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorders, chronic hypokalemia or hypercalcemia, or psychiatric disorders (past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient’s level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary frequency: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient how many times a day he voids. How does this compare to his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for urinary tract infection, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant.

    Obtain a clean-catch midstream sample for urinalysis and culture and sensitivity tests. Then palpate the patient’s suprapubic area, abdomen, and flanks, noting any tenderness. Examine his urethral meatus for redness, discharge, or swelling. In a male patient, the physician may palpate the prostate gland.

    If the patient’s medical history reveals symptoms or a history of neurologic disorders, perform a neurologic examination.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary hesitancy: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed hesitancy and if he’s ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he’s ever been treated for a prostate problem or urinary tract infection or obstruction. Obtain a drug history.

    Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch sample for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary incontinence: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urinary urgency: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient about the onset of urinary urgency and whether he’s ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms, such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract.

    Obtain a clean-catch sample for urinalysis and culture. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient’s history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Urine cloudiness: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent urinary tract infections or recent surgery or treatment involving the urinary tract.

    Obtain a urine sample to check for pus or mucus. (See Peforming the three-glass urine test, page 608.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Cough, barking: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Cough, nonproductive: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

    As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed;  anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

    CULTURAL CUE: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as a cough. Ask the patient at risk for TB — one born in another country, in contact with acute TB, or with high-risk behaviors — about potential TB exposure.

    Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

    Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Cough, productive: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

    Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes. (See Productive cough: Common causes and associated findings, page 168.)

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Lower urinary tract infection: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Characteristic clinical features and a microscopic urinalysis showing red blood cells and white blood cells greater than 10/high-power field suggest lower UTI.

    CONFIRMING DIAGNOSIS A clean-catch midstream urine specimen revealing a bacterial count above 100,000/µl confirms the diagnosis.

    Lower counts don’t necessarily rule out infection, especially if the patient is voiding frequently because bacteria require 30 to 45 minutes to reproduce in urine. Careful midstream, clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.

    Sensitivity testing determines the appropriate therapeutic antimicrobial agent. If patient history and physical examination warrant, a blood test or a stained smear of the discharge rules out venereal disease. Voiding cystoureterography or excretory urography may detect congenital anomalies that predispose the patient to recurrent UTIs.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Whooping cough: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Classic clinical findings, especially during the paroxysmal stage, suggest this diagnosis; laboratory studies will confirm it. Nasopharyngeal swabs and sputum cultures show B. pertussis only in the early stages of this disease; fluorescent antibody screening of nasopharyngeal smears provides quicker results than cultures but is less reliable. In addition, the white blood cell (WBC) count is usually increased, especially in children older than age 6 months and early in the paroxysmal stage. Sometimes, the WBC count may reach 175,000 to 200,000/µl, with 60% to 90% lymphocytes.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Dysuria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter inserted? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.

    During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Oliguria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds, and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Polyuria: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate fluid status first. Take vital signs, noting increased body temperature, tachycardia, and orthostatic hypotension (a 10-mm Hg decrease in systolic blood pressure upon standing and a 10-beats per minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you’ll need to infuse replacement fluids.

    If the patient doesn’t display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient’s level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary frequency: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient how many times a day he voids and how this compares to his previous pattern of voiding. Also ask about the onset and duration of the increased frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain during urination.

    Also ask about neurologic symptoms, such as muscle weakness, numbness, and tingling. Explore the patient’s medical history for UTIs or other urologic problems, recent urologic procedures, and neurologic disorders. Ask a male patient about a history of prostatic enlargement. Ask a female patient of childbearing age whether she is or could be pregnant.

    Obtain a clean-catch midstream urine specimen for urinalysis and culture and sensitivity tests. Then palpate the patient’s suprapubic area, abdomen, and flanks, noting any tenderness. Examine the urethral meatus for redness, discharge, or swelling. The physician may palpate the prostate gland of a male patient.

    If the patient’s history or symptoms suggest a neurologic disorder, perform a neurologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary hesitancy: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem, a UTI, or a urinary tract obstruction. Obtain a drug history.

    Inspect the patient’s urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. A male patient requires prostate gland palpation. A female patient requires a gynecologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary incontinence: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If can control urination occasionally, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he’s ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies and childbirths she has had.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious signs of inflammation or an anatomic defect. Have female patients bear down, and note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urinary urgency: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient about the onset of urinary urgency and whether he’s ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Explore his medical history for recurrent or chronic UTIs and for surgery or procedures involving the urinary tract.

    Obtain a clean-catch urine specimen for urinalysis and culture and sensitivity tests. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient’s history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Urine cloudiness: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; and pain in the flank, lower back, or suprapubic area. Also ask the patient if he has had recurrent UTIs or recent surgery or treatment involving the urinary tract.

    Obtain a urine specimen to check for pus or mucus. (See How to perform the three-glass urine test, page 777.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially if he also has a fever, remove the catheter immediately (or change it if the patient must have one in place).

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Cough, barking: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Cough, nonproductive: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when his cough began and whether any body position, time of day, or specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has any pain associated with coughing, breathing, or activity, when did it begin and where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also ask about recent changes in his appetite, weight, exercise tolerance, or energy level; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

    As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

    Cultural Cue: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB—those born in another country, those in contact with acute TB, and those with high-risk behaviors—about potential TB exposure.

    Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note wheezing or “crowing” noises that occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

    Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Cough, productive: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

    Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Cough: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Characteristics of the cough. What is the type of cough (barking, brassy, wheezy, nocturnal, paroxysmal)? What are the duration, timing, and triggers? Are there associated symptoms of fever, sputum production, dypsnea, hemoptysis, and weight loss? Are there clear relieving factors? Ask specifically about postnasal drip as patients often do not volunteer this information. A good history is the key to diagnosis.

    1. Upper respiratory causes most commonly relate to postnasal drip. In adults, sinusitis, pharyngitis, and allergic rhinitis should be considered. In children, concomitant otitis media should be excluded.

    2. Lower respiratory causes include lung (bronchitis, asthma, pneumonia, bronchiectasis, and in children, foreign body aspiration) and cardiac [congestive heart failure (CHF) and mitral stenosis].

    3. Nonrespiratory causes include GERD, drug effects [e.g., angiotensin converting enzyme (ACE)-inhibitors], and psychogenic.

    B. Smoking patients should be identified early as bronchitis and lung cancer are possibilities. Passive smoking is also a risk factor, especially in children. Office visits for cough represent teachable moments for smoking cessation education. Smoking cessation has been shown to reduce respiratory symptoms by 50%.

     C. Psychosocial impact of the cough reflects severity and the need for further workup. Has the patient missed school or work? Is the sleeping partner disturbed? Is there avoidance of exercise because it triggers cough? In chronic, episodic cough, a correct diagnosis of asthma can considerably improve quality of life. A psychogenic cause for cough and behavioral problems in children may be unmasked here.

    D. Other information. Associated chest pain should direct the history toward pleurisy or rib fracture secondary to chronic cough. Occupational exposures (toxic fumes, chemicals, birds and animals), systemic diseases [rheumatoid arthritis, breast and prostate cancer metastases, human immunodeficiency virus disease (HIV)] and drug exposure (ACE-inhibitors, cyclophosphamide, and methotrexate) are important factors to consider in the cause. Cough with significant weight loss should trigger a workup for TB, HIV, or lung cancer in the smoker.

    Physical examination

     A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

     B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Dysuria: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A good general history is critical and can help direct further questions.

     A. Distinguishing between symptoms of “internal” dysuria and “external” dysuria is often helpful. Internal dysuria is where the discomfort seems to be centered inside the body and begins before or with the initiation of voiding. External dysuria is when the discomfort appears after voiding has initiated. Symptoms of internal dysuria suggest inflammation of the bladder or urethra, whereas those of external dysuria suggest vaginitis, vulvar inflammation, or external penile lesions.

     B. Careful questioning about other associated symptoms and risk factors is the key to sorting out the diagnosis. The history of a new sex partner may support an STD cause. Diaphragm usage may support a bladder infection as well as associated symptoms of frequency, urgency, voiding small volumes, hematuria, and abrupt onset. Gradual onset is more suggestive of urethritis and external causes. Other symptoms of suprapubic pain, costovertebral angle tenderness, fever, flank pain, and so on should be asked about and can direct the diagnostic workup.

    Physical examination

     The physical examination is essential in narrowing the diagnosis. It helps to rule out pyelonephritis and other systemic infections in patients with dysuria, allowing the physician to search for the less severe causes. Fever, flank tenderness, and suprapubic tenderness are useful findings. A careful genital examination (speculum in women, foreskin retraction and prostate examination in uncircumcised men) can point to specific localized causes. The genital examination also allows collection of samples for testing. Attention to localized lesions (e.g., HSV lesions), discharge (yeast, bacterial vaginosis, gonorrhea, and trichomoniasis) and trauma also help make the diagnosis.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Urinary Incontinence: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Voiding history. It is important to fully characterize the patient’s problem by taking a detailed history, including the duration of the symptoms, timing of voluntary or involuntary voiding, amounts voided involuntarily, and the relationship to voluntary voiding. Focus on the following areas:

    1. Need for pads or diapers (measure of severity)

    2. Loss of urine with coughing or laughing (suggests stress type)

     3. Inability to hold urine after having the urge to urinate (suggests urge type)

     4. Pain or discomfort (suggests infection or inflammation) (Chapter 10.1)

    5. Inability to fully empty bladder (suggests obstruction)

    6. Decreased urinary stream (suggests obstruction)

    7. What impact does UI have on the patient’s life?

    8. What does the patient think is going on?

    B. Major medical problems. Does the patient have any known condition that is associated with UI? These include diabetes, heart failure, menopause, and neurologic problems. Does the patient have other genitourinary symptoms? In female patients, be sure to take a detailed obstetric history.

     C. Medication history. Since medications are a major cause of incontinence, a thorough medication history is essential. Offending agents include diuretics, older antidepressants, antihypertensives, narcotics, and alcohol.

     D. Special concern. Central and nephrogenic diabetes insipidus can present with UI because of increased urine output (many liters per day). These patients frequently have a concomitant polydypsia that closely matches their water loss (Chapter 14.5). Consider this diagnosis when the patient gives a history of voiding large volumes of urine.

    Physical examination

     The physical examination is often normal in cases of UI. Focus efforts in an attempt to uncover the underlying cause(s):

    A. General. Is the patient physically capable of getting to the toilet?

    B. Mental status. Can the patient understand and act on the urge to void?

     C. Neurologic, including the anal reflex; focal signs suggest a neurologic cause.

     D. Abdominal examination. Is the bladder distended?

    E. Rectal or prostate. Does the patient have a fecal impaction or an enlarged prostate?

     F. Pelvic examination. Look for atrophic vaginitis, uterine prolapse, or a pelvic mass.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Oliguria and Anuria: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Pertinent present history. A patient may complain of decreased urine output in some clinical situations. More often, however, the clinical situation and pertinent history should lead to an evaluation of the presence of oliguria or anuria.

    1. Are there symptoms of illness or trauma leading to hypotension?

    a. Hypovolemia (e.g., hemorrhage, diuretic overuse, gastrointestinal fluid loss, skin fluid loss owing to burns or heat exposure, third spacing, secondary to burns, peritonitis, pancreatitis, or trauma)?

    b. Decreased cardiac output (e.g., congestive heart failure, myocardial infarction, pericardial tamponade, or acute pulmonary embolus)?

    c. Peripheral vasodilatation (e.g., septic shock, anaphylactic shock)?

     2. Are there symptoms of vascular disease? Consider bilateral renal vascular obstruction due to severe renal artery stenosis, thrombosis, or embolism.

     3. Is there any history consistent with renal parenchymal injury [e.g., recent radiocontrast agent, nephrotoxin exposure such as ethylene glycol, nonsteroidal antiinflammatory drug overdose, acute nephritis, acute vasculitis, pyelonephritis (in the elderly), papillary necrosis (in diabetic patients), or prolonged hypotension with hypoperfusion of the kidney]?

     4. Is there any history consistent with urinary tract obstruction?

     a. Bladder neck obstruction (e.g., benign prostatic hypertrophy, prostate cancer, bladder cancer, or functional obstruction due to drug side effects)?

     b. Obstruction of the urethra or bilateral ureters—internally (2° blood clots, stones, sulfonamide or uric acid crystals, pyogenic debris, necrotizing papillitis or edema), or externally (2° tumor, periureteral fibrosis, accidental ureteral ligation during pelvic surgery, ascites, pregnancy, pelvic abscess, or hematoma).

     5. Medication use must be considered—diuretics, antihypertensives, anticholinergics, aminogycosides, amphotericin B, or chemotherapeutic drugs.

     B. Other pertinent past history. Is there a history of cancer, recent surgery, kidney stones, neurologic disorder, vascular disease, chronic liver disease (hepatorenal syndrome), or kidney transplant?

    Physical examination

    A. Focused physical examination (PE). This should include vital signs (notably blood pressure, pulse, and temperature). Orthostatic blood pressure and pulse may be necessary. Signs of hypovolemia, hypotension, and dehydration should be noted—skin turgor and color, mucous membranes, capillary refill, warmth of extremities.

     B. Additional PE. Depending on the history (e.g., skin rash, cardiac examination, bruits over kidneys) palpate for a distended bladder; if a cancer or outlet obstruction is suspected, perform a rectal or pelvic examination.

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    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Dysuria: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Lower urinary tract infection

    ❑ Acute pyelonephritis

    ❑ Urethritis

    ❑ Vaginitis

    ❑ Acute prostatitis

    ❑ Urethral calculus

    ❑ Reiter syndrome

    Diagnostic Approach

    In women, ask whether burning is internal (urinary tract infection) or external (vaginitis). Women who have had a prior urinary tract infection are more than 90% accurate in identifying recurrences.

    The urine dipstick is a useful diagnostic adjunct for determining the presence of pyuria. Leukocyte esterase and nitrate tests are complementary, increasing the overall sensitivity.

    Always consider a sexually transmitted infection, especially with minimal pyuria and/or a new sexual partner.

    The combination of symptoms of dysuria and frequency without vaginal discharge or irritation has an overall likelihood ratio of 24.6 in predicting acute urinary tract infection.

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    Polyuria is output of 3 L or more daily, and should be differentiated from urinary frequency and nocturia. Nocturia is most commonly due to drinking fluids before sleep, but is also associated with congestive heart failure, cirrhosis, nephrotic syndrome, chronic renal failure and diuretics. Mechanisms of polyuria include: loss of renal concentrating ability (parenchymal disease); decreased bladder capacity; solute diuresis of glucose (diabetes), urea (hypercatabolic states), mannitol, or radiocontrast; postobstructive and post-ATN nephropathy; and decreased responsiveness of the tubule to aldosterone with sodium diuresis (cystic renal disease, Bartter syndrome, or resolving ATN).

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    Proteinuria may present on urinalysis or as edema caused by reduced oncotic pressure from serum albumin loss. The dipstick detects albumin in concentrations of 30 mg/dL (Sensitivity 70%, Specificity 92%, Likelihood ratio 8.8), or 300 to 500 mg of proteinuria per day. False positives may be seen with dehydration and hematuria, both of which can be detected with the dipstick (specific gravity and hemoglobin). False negatives can occur when the protein is a low molecular weight tubular protein (not albumin), e.g., immunoglobulin light chains in myeloma or beta-2 microglobulin. In nephrotic syndrome more than 3.5 grams per day of proteinuria occurs.

    Systemic disease should be suspected in the presence of fever, rash, or arthritis.

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    On examination, test for stress-induced leakage with a full bladder, palpate for bladder distension after voiding, and check for post-void residual. Do a pelvic examination looking for pelvic floor laxity, atrophic vaginitis, urethritis, or pelvic mass, and a rectal examination for tone, fecal impaction, and prostate nodule. Check perineal sensation and neurosacral reflexes including volitional anal contraction, anal wink (anal contraction in response to a light scratch of the perineal skin), and bulbocavernosus reflex (anal contraction in response to a light squeeze of the penis or clitoris). An intact reflex arc but absent perineal sensation suggests a cord lesion or multiple sclerosis.

    Urge incontinence: Due to detrusor overactivity. Urine loss is accompanied by a strong desire to void. Incontinence is preceded by a warning of seconds to minutes. Leakage is periodic but frequent, and nocturnal incontinence is common. Voluntary control of the anal sphincter is intact, and sacral sensation and reflexes are preserved. The post-void residual is low. It is usually a result of detrusor instability caused by stroke, Alzheimer dementia, brain tumor, Parkinson disease, bladder outlet obstruction, spinal cord lesion, or interstitial cystitis.

    Reflex incontinence: Due to an excessive pressure response to bladder filling. Voiding occurs without stress or warning. Sacral reflexes are preserved, but voluntary sphincter control and perineal sensation are impaired. Post-void residual is increased. Usually caused by a spinal cord lesion, incontinence may be mimicked by cortical damage with decreased awareness of signals to void.

    Stress incontinence: Due to failure of the sphincter to remain closed during bladder filling. Incontinence of small amounts of urine occurs with increased abdominal pressure (e.g., coughing, laughing, sneezing). Stress-induced detrusor instability is suggested by a 5 to 15 second delay between stress and leakage, and by nocturnal leakage.

    Overflow incontinence: Due to impaired detrusor contractility and/or bladder outlet obstruction. There is frequent leakage of small amounts of urine, hesitancy, decreased flow, and incomplete emptying. The post-void residual is increased, and the bladder is palpable. Common mechanisms include bladder outlet obstruction caused by benign prostatic hypertrophy or urethral stricture; decreased detrusor tone due to a herniated disc; or peripheral neuropathy caused by diabetes, pernicious anemia, tabes, or cauda equina.

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    Distinguish anuria from urinary retention. Nonobstructive anuria is accompanied by symptoms of uremia with vomiting, drowsiness, muscle twitch, headache, and asterixis. Urinary retention causes suprapubic pain, constant urgency, and a palpable bladder with dullness to percussion in the suprapubic region.

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.

    Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.

    A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.

    » READ BOOK EXCERPT ONLINE »

    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

    Diagnostic Approach

    Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

    Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Urinary tract infection, lower: Diagnosis
    (Handbook of Diseases)

    Characteristic clinical features and a microscopic urinalysis showing red blood cells and white blood cells greater than 10/high-power field suggest lower UTI.

    ❑ A clean-catch, midstream urine specimen revealing a bacterial count of more than 100,000/ml confirms the diagnosis. Lower counts do not necessarily rule out infection, especially if the patient is voiding frequently, because bacteria require 30 to 45 minutes to reproduce in urine.

    Careful midstream, clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.

    ❑ Sensitivity testing determines the appropriate therapeutic antimicrobial agent.

    ❑ Voiding cystoureterography or excretory urography may detect congenital anomalies that predispose the patient to recurrent UTIs.

    ❑  If patient history and physical examination warrant, a blood test or a stained smear of the discharge rules out a sexually transmitted disease.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Cough, barking: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Determine when the barking cough began and other associated signs and symptoms. Determine when the child first appeared to be ill and ask if there have been previous episodes of croup syndrome.

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

    Physical examination

    Assess the respiratory system, noting rate and pattern of respirations. Assess the patient for signs of hypoxia. Stay alert for signs of airway obstruction (nasal flaring, sternal retraction, stridor).

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Cough, productive: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Determine the onset of the cough and amount of daily sputum production. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) Determine the time of day that the most sputum is produced and relationship of food to sputum production. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

    Determine cough characteristics. A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Ask the patient about cigarette, drug, and alcohol use and if there has been weight or appetite changes. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. Determine a medication history, including over-the-counter medications. Ask the patient if his work involves chemicals or respiratory irritants.

    Physical examination

    Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for jugular vein distention, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

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    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Dysuria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, and perineal lotions. Also ask her about vaginal discharge and pruritus.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Oliguria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Polyuria: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorder, chronic hypokalemia or hypercalcemia, or psychiatric disorder (both past and present). Find out the schedule and dosage of any drugs the patient is taking.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary frequency: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient how many times per day he voids. How does this compare to his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for UTI, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant.

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    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary hesitancy: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary incontinence: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he is occasionally able to control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Urinary urgency: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Cough, barking: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Cough, nonproductive: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when his cough began and whether body position, time of day, or specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Cough, productive: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    When the patient’s condition permits, ask when the cough began, and find out how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [88.7 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats, or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants, such as silicone?

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Cough: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Infection/Inflammation

    Upper Respiratory Tract Infection

  • URI (commoncold) is acute viral infection.
  • Common pathogens include rhinoviruses,parainfluenza viruses, respiratory syncytial virus (RSV), and coronaviruses.Other viruses that occasionally cause common cold are adenoviruses,enteroviruses, influenza viruses, and reoviruses.
  • Usual clinical findings are watery,mucoid, or purulent discharge; dry, hacking cough; and inflamednasal mucosa.
  • Diagnosis is clinical.

    • Sinusitis

  • Usuallypresents with history of purulent nasal discharge and persistentcough of >10 days' duration. Less common presentationis combination of fever, headache, and facial pain or sinus tenderness.
  • Usually clinical diagnosis.
  • CT should be performed when orbitalabscess or intracranial complication is suspected.

    • Laryngitis

  • Most frequentcause is viral URI.
  • Hoarseness and dry, hacking cough,which may last up to 1 wk, are usual clinical findings.
  • Usually clinical diagnosis.

    • Croup

  • Characterizedby a barking cough and stridor ± fever.
  • See Chap.63, Stertor, Stridor, and Airway Obstruction.

    • Tracheitis

  • Often crouplikeillness with cough and stridor precedes sudden onset of respiratory distressand high fever.
  • Clinical picture suggests bacterialtracheitis.
  • See Chap.63, Stertor, Stridor, and Airway Obstruction.

    • Bronchitis

  • Inflammatoryprocess affecting trachea and bronchi. Most episodes are causedby viruses (e.g., RSV, parainfluenza viruses, influenza viruses,rhinoviruses, and adenoviruses).
  • Hacking cough appears several daysafter onset of typical URI. Rhonchi may be heard, but crackles areinfrequent. Presence of wheezing usually indicates presence of reactiveairways disease.
  • Usually clinical diagnosis.

    • Pertussis

  • B. pertussisinfection begins with nasal discharge, which is followed by paroxysmal coughthat often has staccato quality. Whoop may follow paroxysm.
  • Fever may or may not occur.
  • There is usually leukocytosis withpredominance of lymphocytes.
  • Apnea is serious complication, especiallyin young infants.
  • Duration of illness may be as longas 6–10 wks.
  • Chest radiograph may be normal or showperihilar infiltrates.
  • Positive direct immunofluorescent assayof nasopharyngeal secretions suggests diagnosis, but false-positiveand false-negative results occur.
  • Positive nasopharyngeal culture confirmsdiagnosis.

    • Bronchiolitis

  • Usuallycaused by RSV and occasionally by parainfluenza viruses, influenzaviruses, and adenoviruses.
  • Occurs during winter months, oftenin epidemics.
  • Rhinorrhea usually precedes cough,which may be persistent and harsh. Expiratory wheezing is prominentfinding.
  • See Chap.75, Wheezing.

    • Pneumonia

  • Definedas inflammation of lung parenchyma that may be caused by infection.
  • Frequently presents with fever, cough,and respiratory distress. Crackles and wheezes may be heard on exam.Decreased breath sounds and dullness to percussion indicate areaof lung consolidation.
  • Presence of pneumonia usually can beconfirmed by chest radiography, although early in illness radiographcan appear normal.
  • Specific cause requires further investigation.

    • Viral

  • Accountsfor most cases of pneumonia in infancy and childhood.
  • Most common viruses causing pneumoniainclude RSV, parainfluenza viruses, adenoviruses, and influenzaviruses. Less common causes are rhinoviruses and coronaviruses.
  • Cytomegalovirus and herpes simplexvirus may cause pneumonia in newborn or in immunocompromised individuals.
  • May also be caused by measles, varicella,and Hantavirus infection.
  • Chest radiograph frequently shows involvementof both lungs, with peribronchial thickening, perihilar linear densities,and patchy infiltrates. Segmental or lobar consolidation, hilaradenopathy, and pleural effusions are unusual.
  • Nasal wash cultures or polymerase chainreaction (PCR) of nasal secretions may sometimes diagnose specificviral infection.
  • RSV antigen may be detected by enzymeimmunoassay or immunofluorescent techniques.

    • Bacterial

  • Pathogenscausing bacterial pneumonia vary with age of child.
  • Most common causes of bacterial pneumoniain neonates are group B Streptococcus and gram-negative entericbacteria (E. coli, K. pneumoniae, P. aeruginosa).
  • In infancy, childhood, and adolescence,S. pneumoniae is most common, whereas S. aureus and group A Streptococcusare much less common.
  • H. influenzae type b has become unusualcause of pneumonia, since advent of H. influenzae vaccine.
  • M. tuberculosis can cause infectionat any age.
  • Clinical findings with bacterial pneumoniausually include fever, cough that may be productive of sputum inolder child, and some degree of respiratory distress.
  • Leukocytosis with predominance of polymorphonuclearleukocytes is common finding.
  • Pleural effusions and pneumatocelesare more frequent with bacterial pneumonia than with viral pneumonia.
  • Chest radiograph usually shows segmentalor lobar infiltrate.
  • Diagnosis of bacterial pneumonia canbe confirmed by positive blood, pleural fluid, or lung biopsy cultures.McCarthy et al. (1999) demonstrated that PCR may be used to diagnosepneumonia caused by S. pneumoniae using sample of pleural fluid.
  • Pharyngeal or sputum culture that haslarge numbers of single organism is suggestive but not diagnostic.
  • Counterimmune electrophoresis and latexagglutination tests have successfully detected bacterial antigensof S. pneumoniae, group B Streptococcus, and H. influenzae typeb in urine, so these tests may be diagnostic.

    • Tuberculosis

  • Usual modeof transmission of M. tuberculosis infection is by inhalation.
  • Positive skin test with PPD may beobserved 2–12 wks after exposure.
  • Children with disease usually haveprimary pulmonary TB with cough and fever.
  • In most cases of TB infection, individualis asymptomatic, primary complex of infection is not seen on chestradiograph, and disease does not progress.
  • In TB disease, individual has clinicalor radiographic findings and disease may be pulmonary or nonpulmonary.
  • Chest radiograph shows involvementof segment or lobe, usually with enlarged regional lymph nodes.With progression, cavitary lesions or miliary disease can occur.
  • Acid-fast bacilli smears and culturesshould be performed in anyone with suspected TB. In young child,especially if cough is nonproductive, best culture material is fromearly morning gastric aspirate. Otherwise, isolation of tuberclebacilli by culture of sputum, urine, pleural fluid, cerebrospinalfluid, other body fluids, or biopsy material confirms diagnosis.
  • Negative PPD never excludes infectionor disease with TB. Anergy may be due to young age, viral infections,immunosuppression, and severe disseminated TB.

    • Chlamydia

  • Pneumoniadue to C. trachomatis usually occurs in infants 1–3 mosof age.
  • Clinical findings include conjunctivitisor history of conjunctivitis, staccato cough, tachypnea, crackles,and mild peripheral eosinophilia. Fever is variable finding.
  • Chest radiograph usually shows hyperinflationand bilateral interstitial infiltrates.
  • Positive nasopharyngeal or eye cultureconfirms diagnosis.

    • Legionella

  • Legionnaire'sdisease is transmitted by inhalation of aerosolized water contaminated withLegionella species.
  • Most common cause of Legionella infectionin U.S. is L. pneumophila serogroup 1.
  • Frequent findings include fever, nonproductivecough, headache, and myalgia.
  • Chest radiograph usually shows infiltrate.Pulmonary nodules ± cavitation also may occur.
  • Diagnosis can be confirmed in a numberof ways:

  • positiveculture of sputum or lung tissue
  • detection of organisms on smears ofrespiratory tract secretions by direct immunofluorescent assay usingmonoclonal or polyclonal antibodies
  • DNA probes
  • serologic testing using indirect immunofluorescenceantibody assay
  • Increase in antibody titer to ≥1:128is also considered diagnostic.

    • Nocardia

  • Nocardiaspecies are funguslike bacteria that live in soil.
  • Lung is probable portal of entry aswell as most frequent site of infection.
  • Most common agent in U.S. is N. asteroides.
  • Clinical findings include fever, cough,chest pain, night sweats, malaise, and weight loss.
  • Chest radiography shows scattered infiltrates.
  • Stained smears of sputum, spinal fluid,or pus may reveal gram-positive rods that are variably acid fast.
  • Positive culture confirms diagnosis.

    • Mycoplasma

  • M. pneumoniaeis common cause of pneumonia in school-aged children and adolescents.
  • Infection with this organism is uncommonin patients <5 yrs of age.
  • Persistent nonproductive cough andfever are usual presenting features. Other findings include headache,myalgia, sore throat, and macular or papular rash. Crackles andwheezes may be heard on lung exam.
  • Typically, chest radiograph shows patchy,unilateral, segmental, or subsegmental consolidation, but diffuse,bilateral, interstitial infiltrates may be seen.
  • Cold agglutinin titer of ≥1:64 issuggestive of diagnosis, although other viral infections (adenoviruses,Epstein-Barr virus) also can produce elevated titer. Complementfixation test is most widely available serologic test, and titerof ≥1:32 during an acute respiratory illness is suggestive ofinfection.

    • Fungal

    Histoplasmosis

  • Endemicin eastern and midwestern U.S., especially in Mississippi and OhioRiver valleys.
  • Infection occurs by inhalation of H.capsulatum spores, which are present in soil or dust in barnyardsor other areas that contain bird and bat droppings.
  • >95% of infectionsare asymptomatic. Common presentation is acute influenza-like illness withpulmonary infiltrates and hilar adenopathy. Disseminated diseasewith fever, cough, pulmonary infiltrates, hepatosplenomegaly, andpancytopenia occurs most frequently in immunocompromised hosts.
  • Culture of sputum, blood, or bone marrowconfirms diagnosis, as does demonstration of intracellular yeastsin smears of bone marrow or biopsy material from infected tissues.
  • Detection of H. capsulatum antigenin urine or serum also can be used to diagnose disseminated disease.Single titer of ≥1:32 or 4-fold increase in yeast phase titersis presumptive evidence of active infection. H bands found in immunodiffusionantibody assay also suggest active infection.

    • Coccidioidomycosis

  • Endemicin southwestern U.S. Transmission occurs by inhalation of dust-borne sporesof C. immitis.
  • Primary infection is often asymptomatic,whereas symptomatic infection usually presents with fever and cough.
  • Chest radiograph may show hilar adenopathyand calcification of healing primary lesion. Granulomatous lesionscan occur in lungs, lymph nodes, bones, joints, skin, and meninges.
  • Typical clinical and radiologic findingsand positive skin test or ≥1:32 complement fixation antibodytiter are diagnostic. Spherules seen in tracheal aspirates, sputum,urine, or spinal fluid; biopsies of skin lesions or organs; or positivecultures from any of these sources are also diagnostic.

    • Aspergillosis

  • Aspergillusspecies grow in soil and in decaying vegetation. Transmission isby inhalation of airborne spores.
  • Different clinical presentations mayoccur:

  • Allergicbronchopulmonary aspergillosis with low-grade fever, productivecough, episodic wheezing, transient pulmonary infiltrates, and eosinophilia
  • Aspergillomas that do not invade lungtissue
  • Invasive pulmonary disease with feverand productive cough
  • Disseminated disease with involvementof skin (cutaneous papules and abscesses), heart (endocarditis),bone (osteomyelitis), sinuses (sinusitis), or brain (abscess).
  • Chest radiograph may show patchy ornodular infiltrates or consolidation ± cavitation.
  • Branching and septate hyphae in sputumsuggest diagnosis.
  • Positive sputum or lung biopsy cultureconfirms diagnosis.

    • Blastomycosis

  • Infectionwith B. dermatitidis is endemic in southeastern U.S. and in midwestern statesbordering the Great Lakes.
  • Pulmonary, cutaneous, and disseminatedforms of disease can occur, but pulmonary disease is most commonin children.
  • Clinical findings of pulmonary diseaseinclude cough, fever, malaise, chest pain, weight loss, and hemoptysis.
  • Chest radiograph may show infiltrates,cavities, or nodular densities.
  • Primary cutaneous blastomycosis maypresent with ≥1 subcutaneous nodules that eventually ulcerate.
  • Disseminated disease produces granulomatouslesions, which may involve liver, spleen, bone, skin, and brain.
  • Thick-walled single budding yeast formsmay be seen with 10% KOH preparations from sputum, spinalfluid, urine, or skin lesions.
  • Positive immunodiffusion test on serathat shows precipitin bands (A and B) is evidence for active infection;however, bronchoalveolar lavage or lung biopsy may be necessaryto establish diagnosis in children with pneumonia.
  • Serologic assays are not reliable fordiagnosis.

    • Protozoa

  • P. cariniiinfection occurs almost exclusively in immunocompromised childrenand is common in those affected with HIV.
  • Clinical findings include nonproductivecough and fever.
  • Chest radiograph shows bilateral interstitialor air-space disease.
  • Diagnosis is confirmed by demonstrationof organism in lower respiratory tract secretions or lung tissue.
  • Induction of sputum in older childrenand adolescents, bronchoscopy with bronchoalveolar lavage, or lungbiopsy can be performed.
  • Methenamine silver nitrate and toluidineblue O are most useful stains to identify thick-walled cysts.

    • Chemical Pneumonia

  • Gasoline,kerosene, and charcoal lighter fluid are hydrocarbons with low surfacetension and viscosity. Because of these properties, aspiration intotracheobronchial tree can easily occur after ingestion.
  • Acute onset of cough and respiratorydistress and history of ingestion are diagnostic. Within severalhours of ingestion, chest radiograph may show evidence of pneumonia,with infiltrates commonly in right middle and lower lobes.

    • Aspiration Pneumonia

  • Interferencewith normal swallowing predisposes to aspiration of oral and gastricsecretions as well as food. Children with gastroesophageal reflux,tracheoesophageal fistula, or neurologic disorders with swallowingdysfunction are more prone to develop aspiration pneumonia.
  • Onset of respiratory distress afterchoking, gagging, coughing, or vomiting episodes should lead oneto suspect aspiration pneumonia.

    • Cystic Fibrosis

  • Common causeof chronic lung disease in children but also affects other organsystems with epithelial surfaces, especially intestine, pancreas,liver, and sweat glands. Mutations in CFTR gene located on chromosome7 result in abnormal ion transport across epithelial surfaces. Genetictransmission is autosomal recessive.
  • Age of onset and clinical presentationvary widely. Earliest clinical manifestation is meconium ileus innewborn. Most common manifestation of respiratory disease is coughthat may be dry or productive. Other clinical findings include wheezing;nasal polyps; frequent large, foul-smelling stools; digital clubbing;recurrent rectal prolapse; and poor growth.
  • Chest radiograph usually shows hyperinflation,irregular aeration with areas of patchy atelectasis, and accentuatedperibronchial markings.
  • Bacterial organisms that commonly colonizerespiratory tract in this disease are S. aureus, H. influenzae,and gram-negative enteric bacteria, including P. aeruginosa.
  • Sweat chloride level >60 mEq/Lis diagnostic.
  • DNA mutation analysis is definitive.

    • Bronchiectasis

  • Infectionor chronic inflammation of airways can cause bronchiectasis.
  • May be focal (foreign body, local infection)or generalized (cystic fibrosis, chronic aspiration).
  • Chronic productive cough with cracklesand rhonchi on lung exam are usual findings.
  • Chest radiography may show persistentatelectasis or infiltrates that fail to resolve.
  • Diagnosis may be confirmed by chestCT, which shows dilated bronchi that do not taper peripherally.

    • Lung Abscess

  • May occur ± pneumonia.
  • Most common organisms found in lungabscesses are Staphylococcus species and group A Streptococcus.Anaerobes also may play role in individuals with aspiration pneumonia.
  • Persistent fever and cough are usualclinical features.
  • Abscess (density with air-fluid level)may be seen on chest radiography, with confirmation by chest CT.
  • Needle aspirate may reveal specificpathogen.

    • Allergic Disorders

    Allergic Rhinitis

  • Althoughusual clinical findings with allergic rhinitis are persistent orrecurrent rhinorrhea, sneezing, and itchy tearing eyes, nonproductivecough also occurs.
  • See Chap.41, Nasal Discharge.

    • Asthma

  • Definedas inflammatory disorder of smaller airways, which is characterizedby recurrent wheezing that is reversible with bronchodilator therapyor spontaneously. Another common manifestation is recurrent cough, ± wheezing,especially after exercise or at night.
  • See Chap.75, Wheezing.

    • Mechanical or Chemical Irritation

    Environmental Irritants

  • Smoke, chemicalfumes, particulate matter from fire, and other environmental pollutantsand toxins may stimulate cough production.
  • History of exposure is diagnostic.

    • Foreign Body Aspiration

  • Aspirationof foreign body into bronchus commonly produces choking or gagging followedby persistent coughing or wheezing.
  • Some common foreign bodies are food(nuts, seeds, meat), pins, tacks, and plastic tops.
  • Chest radiography may show segmentalor lobar collapse or unilateral hyperinflation. Chest radiographstaken in inspiration/expiration or in right and left lateraldecubitus positions as well as fluoroscopy may demonstrate unilateralair trapping and movement of mediastinum away from affected side duringexpiration. In some cases, bronchoscopy is necessary to confirmdiagnosis.

    • Bronchopulmonary Dysplasia

  • A form ofchronic lung disease that often follows neonatal respiratory distresssyndrome treated with endotracheal intubation, mechanical ventilation,and high concentrations of inspired oxygen.
  • During course of disease, respiratorydistress waxes and wanes with intermittent cough.
  • Crackles and rhonchi may be heard onlung exam.
  • Hypoxemia and hypercapnia occur, andapnea may develop.
  • Chest radiograph shows combinationof hyperinflation, prominent perihilar markings, and streaky densitiesthat may persist for many months.

    • Congenital Anomalies

  • Congenitalanomalies that may produce cough include laryngomalacia, tracheomalacia,tracheoesophageal fistula, pulmonary sequestration, bronchogeniccyst, cystic adenomatoid malformation, and vascular rings and slings.
  • See Chap.56, Respiratory Distress and Apnea, Chap. 63, Stertor, Stridor, and Airway Obstruction,and Chap. 65, Sucking and SwallowingDifficulty.

    • Cardiac Failure

  • Pulmonaryvenous congestion occurring as manifestation of cardiac failuremay cause airway edema leading to cough. Other findings includerespiratory distress, tachycardia, hepatomegaly, and cardiomegaly.
  • See Chap.7, Cardiac Failure.

    • Gastroesophageal Reflux

  • Aspirationof stomach contents into lung may produce airway obstruction andpneumonia with coughing and wheezing. Another proposed mechanismfor cough and respiratory distress is the stimulation of esophagealvagal afferents by gastric contents to produce laryngospasm andbronchospasm.
  • See Chap.55, Regurgitation and Vomiting.

    • Swallowing Dysfunction

  • Disordersthat cause difficulty in swallowing may produce gagging, choking,and recurrent coughing.
  • See Chap.65, Sucking and Swallowing Difficulty.

    • Immotile Cilia Syndrome

  • Autosomal-recessivedisorder characterized by defects in ultrastructure of cilia that impairciliary motion and clearance of mucus from respiratory tract.
  • 1 form of this syndrome has been mappedto chromosome 9p21-p13, whereas another has been mapped to chromosome5p.
  • Structural defects include absenceof dynein arms and radial spokes.
  • Onset is in infancy or early childhoodwith chronic cough that is usually productive of sputum. Other manifestationsinclude chronic rhinitis, sinusitis, otitis media, bronchitis, andpneumonia.
  • Chest radiograph may show hyperinflation,bronchial wall thickening, segmental atelectasis or consolidation,situs inversus, and bronchiectasis.
  • Electron microscopy of cilia obtainedby nasal or bronchial biopsy brushing techniques demonstrates structuraldefects.

    • Neoplasm

  • Chroniccough may occur with airway tumors (hemangioma, papilloma), mediastinal masses,and lung tumors, including metastatic lesions.
  • See Chap.56, Respiratory Distress and Apnea.

    • Reflex Cough

  • In somechildren, foreign body or cerumen in ear canal causes transientreflex cough.
  • Persistent cough also has been attributedto hair lodged against tympanic membrane.
  • Otoscopic exam is diagnostic.

    • Psychogenic/Habitual Cough

  • Occasionallychild has persistent or recurrent cough with no evidence of underlying respiratorytract disease. Usually occurs in school-aged child after URI, andcough lasts for weeks.
  • Cough is usually loud, harsh, and foghorn-like,disappearing during sleep and often decreasing when alone or onweekends.
  • Otherwise, child is well and physicalexam and chest radiograph are normal.
  • Often secondary gain can be identified.Some of these children may have emotional problems that requirefurther evaluation.

    • Diagnostic Approach

  • In manycases history and physical exam are diagnostic.
  • Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities.

    • Age of Child and Duration of Cough

  • In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.
  • In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).
  • Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.
  • Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.
  • In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.
  • Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems.

    • Periodicity and Quality of Cough

  • Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.
  • Recurrent viral URIs and asthma causeepisodic coughing.
  • Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.
  • Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.
  • Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.
  • Neuromuscular disorders produce a weakand feeble cough.
  • Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease.

    • Timing of Cough

  • If coughdisappears while asleep, it usually has psychologic basis.
  • Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.
  • Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis.

    • Nature of Sputum Production

    Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.

    Associated Findings

  • Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.
  • Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.
  • Cough associated with stridor indicatesairway obstruction.

    • Evaluation

  • Etiologyof cough can usually be determined or at least suspected from historyand physical exam.
  • Chest radiography shows pattern andextent of disease and is confirmatory in many instances.
  • With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.
  • If TB is suspected, intermediate-strengthPPD should be placed.
  • Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.
  • With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.
  • Another useful test is sweat test inchildren with recurrent or chronic cough.
  • With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step.
    • >

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Dysuria: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Urinary Tract Infection (UTI)

  • UTI existswhen a significant number of bacteria are present in urine or whenthe urinary tract is infected with a virus. Infection can involveurethra, bladder, or renal parenchyma.
  • E. coli is most common pathogen inall age groups. Other pathogens include gram-negative enteric bacteria(Klebsiella, Proteus, Pseudomonas, and Enterobacter species) andgram-positive bacteria (Enterococcus species, coagulase-negativeStaphylococcus, group B Streptococcus, S. aureus).
  • Only virus likely to be encounteredas urinary tract pathogen is adenovirus, which causes acute hemorrhagiccystitis.
  • Manifestations vary with age. In neonatesclinical features include fever or temperature instability, poorfeeding, decreased activity, and vomiting. Fever, vomiting, anddecreased weight gain may occur in infants. In children and adolescents,common findings include fever, dysuria, frequency, urgency, vomiting,abdominal pain, and flank pain. In all age groups urine may be cloudyand foul smelling.
  • Pyuria and microscopic or gross hematuriamay be found. Positive urine culture is diagnostic.

    • Urethritis

  • In girlsvulvovaginitis is a common cause of urethritis. See Chap. 71, Vaginal Discharge.
  • Occasionally, dysuria occurs with labialadhesions, which are readily seen on physical exam. Proposed mechanismis pooling of urine behind adhesion and inadequate cleansing ofurethra.
  • In boys urethritis occurs most commonlyin adolescents. N. gonorrhoeae and C. trachomatis are the most commonpathogens in this age group.
  • Gonorrhea usually presents with creamyurethral discharge and dysuria 2–7 days after sexual contact.Gram-stained smear of discharge that shows gram-negative intracellulardiplococci is diagnostic, whereas positive culture of urethral dischargeis confirmatory.
  • Infection with C. trachomatis may ormay not produce mild mucoid discharge, and dysuria is usually mild.Positive urine culture is diagnostic.
  • When herpes simplex virus causes urethritis,vesicles are usually seen on genital exam.

    • Cystitis

  • Infectionof bladder with bacteria is common in girls but infrequent in boys.Long male urethra and bactericidal prostatic secretions may be responsiblefor lower incidence in boys.
  • Children with cystitis may have dysuria,urinary frequency, urgency, suprapubic tenderness, and occasionallyfever.
  • If dysuria persists in sexually activeindividuals and urine bacterial culture is negative, urine shouldbe cultured for C. trachomatis.
  • Adenovirus infection of bladder cancause severe dysuria and bloody urine (hemorrhagic cystitis). Usualurine culture for bacteria is sterile.

    • Pyelonephritis

  • Childrenwith acute pyelonephritis do not have dysuria unless cystitis isalso present. They are usually more ill and have higher fever thanthose with urethritis or cystitis.
  • Parenchymal infection should be suspectedin febrile child with flank pain and tenderness who may or may notbe toxic.
  • Renal scintigraphy using technetium99m–dimercaptosuccinic acid can show renal cortical involvementin most cases.

    • Chemical Irritation

  • Chemicalirritants, which include detergents, fabric softeners, perfumedsoaps, and bubble baths, are common causes of transient urethritis.
  • History and physical exam are diagnostic.

    • Diaper Dermatitis

  • Diaper dermatitiswith or without Candida infection can cause meatal inflammation withulcer formation in boys and urethral inflammation in girls.
  • History and physical exam are diagnostic.

    • Trauma

  • Any injuryto urethra (e.g., minor trauma, foreign body placed in urethra,or child abuse) can produce dysuria. Hematuria with or without bacteriuriaalso may occur.
  • History and physical exam are oftendiagnostic.
  • Urethrogram or cystogram may be necessaryif there is history of trauma and persistent hematuria. Pelvic radiographymay reveal radiopaque foreign body.

    • Psychogenic

    Dysuria may occur for psychologic reasonswithout any pathologic process involving genitourinary tract.

    Diagnostic Approach

    History and physical exam are usually diagnosticof trauma, vulvovaginitis, labial adhesions, chemical irritation,and diaper dermatitis. Otherwise, suspect UTI and perform UA andurine culture.

    Urinalysis

  • Presenceof WBCs (>10/high-power field) in sediment ofcentrifuged specimen of urine suggests but is not diagnostic ofUTI. Neither is positive leukocyte esterase test (urine dipstick), whichindicates presence of WBCs in urine.
  • Positive nitrite test using nitritestrip (Griess test) on urine dipstick is highly sensitive and specificfor detection of gram-negative bacteria (e.g., E. coli, Klebsiella,and Proteus species). Positive reaction usually indicates 105 CFUs/mL.False-positive reactions are uncommon if urine is fresh; however,if urine is not examined immediately, test result may be positivebecause of bacteria growing at room temperature. False-negativereactions may occur when there has been inadequate time for bacterialproliferation (random collection rather than first morning specimen)or when infection is due to Enterococcal species and some Staphylococcaland Pseudomonas species that do not convert nitrate to nitrite.
  • Presence of ≥1 bacteria/oilimmersion field of unspun urine (unstained or Gram stain) from clean-catchmidstream specimen correlates with urine colony count of >105 CFUs/mL80–95% of the time.

    • Urine Culture

    Quantitative culture of properly collectedurine specimen establishes diagnosis of UTI, and susceptibilitytesting can be performed. Table15.1, based on data from many studies, is useful guidefor diagnosis of UTI.

    Table 15.1. Criteria for Diagnosis of Urinary Tract Infections

    Method of CollectionColony Counta (Pure Culture)Probability of Infection (%)
    Suprapubic aspirationGram-negative bacilli: any number>99
    Gram-positive cocci: > a few thousand
    Catheterization>10595
    104–105Infection likely
    103–104Suspicious; repeat
    <103Infection unlikely
    Clean-voided (male)>104Infection likely
    Clean-voided (female)3 specimens: >10595
    2 specimens: >10590
    1 specimen: >10580
    5 × 104–105Suspicious; repeat
    104 to 5 × 104Symptomatic; suspicious; repeat
    104 to 5 ×104Asymptomatic; infection unlikely
    <104Infection unlikely
    aCFUs/mL of single isolate.From Hellerstein S. Recurrent urinary tract infections inchildren. Pediatr Infect Dis 1982;1:275, with permission.

    Radiologic Imaging

  • Differencesof opinion exist concerning usefulness of radiologic studies inevaluation of children with UTI. Studies are performed to searchfor anatomic abnormalities that may predispose to infection andalso to identify presence of vesicoureteral reflux.
  • In our hospital when infant or childhas first UTI, initial studies include renal U/S in both girlsand boys followed by a radionuclide voiding cystourethrogram ingirls and contrast voiding cystourethrogram in boys.
  • Use of renal cortical scintigraphyis controversial, but it can help diagnose acute pyelonephritisand identify renal scarring.
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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Proteinuria: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Functional/Transient Proteinuria

    Fever, exercise, extreme cold, cardiac failure,seizures, and emotional stress can cause transient proteinuria.Diagnosis is usually made by history, physical exam, and clinicalcourse. Proteinuria measured on dipstick is usually <2+.

    Postural Proteinuria (Orthostatic)

    Occurs when patient is in upright position,not recumbent. Can be transient or persistent and is unusual before7 yrs of age. Long-term prognosis is benign.

    Nephrotic Syndrome

  • Characterizedby proteinuria, hypoproteinemia, edema, and hyperlipidemia.
  • Congenital (Finnish type) form, whichis autosomal recessive, presents during first 3 mos of life. Mostcommon cause in children is minimal change disease, which most commonlyoccurs at 2–6 yrs of age. Other causes include focal glomerulosclerosis,mesangial proliferative glomerulonephritis, lupus nephritis, anddrug exposure (captopril, lithium, penicillamine, procainamide,NSAIDs).
  • Initial episode of nephrotic syndromeas well as relapses often follow viral URIs. First sign of generalizededema may be ankle or eyelid edema, and pleural effusions and ascitesalso may occur. UA usually reveals +3 or +4 proteinuria.Although microscopic hematuria can occur, gross hematuria is unusual.Serum albumin is usually <2 g/dL, whereas serumcholesterol and triglycerides are increased. Renal function maybe normal or impaired.
  • In children <6 yrs of age,in whom minimal change disease is most likely, corticosteroids canbe given as diagnostic and therapeutic trial. Lack of therapeuticresponse with persistence of proteinuria for >4–6wks is indication for renal biopsy.

    • Tubulointerstitial Disease

    Reflux Nephropathy

  • Occurs asconsequence of vesicoureteral reflux, which is abnormal retrogradeflow of urine from bladder into upper urinary tract.
  • Proteinuria, hypertension, and chronicrenal insufficiency may occur. History of recurrent urinary tractinfection is frequent.
  • Combination of renal U/S,voiding cystourethrography, and renal scintigraphy is commonly usedto evaluate reflux and its effects. Reflux may be graded from Ito V, with V being most severe.
  • Diagnosis is usually clinical and radiologic.

    • Tubulointerstitial Nephritis

  • Syndromewith inflammation and damage of tubular and interstitial structuresand relative sparing of glomerular and vascular structures.
  • Common causes include infection (mostcommonly pyelonephritis and streptococcal infections), drugs (penicillins,sulfonamides, cephalosporins, phenytoin, thiazides, furosemide,allopurinol, amphotericin B, NSAIDs), and idiopathic.
  • Clinical manifestations vary from mildazotemia to oliguric renal failure. Proteinuria may occur aloneor with hematuria (usually microscopic).
  • Renal biopsy is necessary for definitivediagnosis, unless serum creatinine begins to decrease followingwithholding of suspected offending agents.

    • Fanconi Syndrome

  • This autosomal-dominantdisorder whose gene locus has been mapped to chromosome 15q15.3is characterized by

  • Generalized dysfunction of proximal tubuletransport causing excessive urinary excretion of amino acids, glucose,phosphate, bicarbonate, and other solutes
  • Vitamin D–resistant metabolicbone disease (rickets in children)
  • Clinical features include aminoaciduria,proteinuria, glycosuria, hypokalemia, hypophosphatemia, metabolicacidosis, rickets, and impaired growth.
  • This syndrome also may be associatedwith cystinosis (most common), galactosemia, hereditary fructoseintolerance, tyrosinemia, Wilson disease, Lowe syndrome, lead poisoning,and drugs (aminoglycosides, cisplatin, valproic acid).

    • Ischemic Tubular Injury

  • Acute tubularnecrosis usually occurs as result of prerenal failure or after severehypoxic insult.
  • UA may be unremarkable or show low-gradeproteinuria and granular casts. There is inability to conserve sodiumand water.
  • Renal U/S shows normal-sizedkidneys with loss of corticomedullary differentiation, and renalscintigraphy demonstrates decreased renal function.

    • Benign Persistent Proteinuria

  • Persistentproteinuria without evidence for postural proteinuria or renal disease.
  • Renal biopsy is normal or shows minimalnonspecific changes.
  • This is a diagnosis of exclusion.
  • Even though this is a benign disorder,follow-up is important because focal glomerulosclerosis may presentsimilarly.

    • Diagnostic Approach

  • First stepin evaluation of a child with proteinuria is to determine if thereare any predisposing factors for transient or functional proteinuria(e.g., fever or strenuous exercise).
  • If history is negative for these factorsand dipstick protein is persistently ≥1+, next step isto do complete UA and determine protein:creatinine ratio in a firstmorning spot urine specimen.
  • If results of UA are normal and protein:creatinineratio is in normal range, diagnosis is postural proteinuria andno further studies are necessary.
  • If results of UA are otherwise abnormalor first morning protein:creatinine ratio is above normal, furtherstudies are necessary. Serum electrolytes, creatinine, albumin,and cholesterol as well as blood urea nitrogen should be measured,and renal U/S should be performed. C3 and antinuclear antibody shouldbe considered.
  • If diagnosis remains uncertain andno chemical or radiographic evidence of renal disease exists, renalbiopsy may be performed or child may tentatively be considered tohave benign persistent proteinuria. If renal biopsy is not performedor is normal, child should be monitored at 6-mo intervals for urinaryand chemical changes indicative of renal disease.
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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Urinary Incontinence: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Maturational Delay

  • Most commoncause of primary urinary incontinence is lag in maturation of normal inhibitingmechanism of urine control. There is often family history of incontinence.
  • Many children may achieve daytime controlbut still experience incontinence during sleep.
  • This is a diagnosis of exclusion inan otherwise normal child who has no evidence of organic disease,no history of stress-related or psychologic disturbance, and normalUA and urine culture.
  • At 5–10 yrs of age, spontaneouscure rate of nocturnal enuresis is about 15%/yr.

    • Stress-Related Causes

    Stress is frequent cause of secondary incontinence.Examples of stress-related factors are illness, separation, birthof sibling, attending new school, death of family member, divorcein family, and other personal and family problems. Once problemis recognized, proper support and counseling usually help with itsresolution.

    Urinary Tract Disorders

    Urinary Tract Infection

  • May causenighttime and daytime incontinence.
  • Other common findings include fever,dysuria, urinary frequency, abdominal or flank pain, and vomiting.
  • Positive urine culture confirms diagnosis(see Chap. 15, Dysuria).

    • Dysfunctional Voiding Disorders

  • Voidingdysfunction occurs in many children who do not have known organiccause (e.g., neurologic disorder, injury, or malformation).
  • Although some children have small-capacitybladder and experience urgency and often incontinence, others havehyperreflexic bladder with uninhibited detrusor contractions duringfilling. Still others have large hypotonic bladder that does notempty completely with voiding.
  • Failure to empty bladder results inchronically distended bladder that is prone to urinary tract infectionand overflow incontinence.
  • Urinary urodynamic testing is helpfulin determining abnormality in each case.

    • Lower Urinary Tract Obstruction

  • Can producebladder distension and overflow incontinence. Poor urinary streamwith dribbling and excessive straining with urination are prominentfeatures.
  • Specific causes include posterior urethralvalves, urethral duplication, or urethral cyst.
  • Combination of tests including renalU/S, intravenous urography, and voiding cystourethrographyusually can confirm diagnosis. Retrograde urethrography is generallyrequired for adequate evaluation of urethral duplication.

    • Ectopic Ureter in Girls

  • Ectopicureter may empty into bladder neck, urethra, vagina, or, rarely,uterus with continuous leakage of small amount of urine. Child hasnormal voiding habits but is frequently wet.
  • Because of frequent occurrence of completeureteral duplication and associated renal parenchymal dysplasiain segment drained by ectopic ureter, renal U/S, intravenousurography, and voiding cystourethrography are useful in evaluation.
  • If diagnosis remains uncertain afterthese studies, but ectopic ureter is still suspected, magnetic resonanceurography may be diagnostic. Cystoscopy can help identify ureteralorifice if it is in urethra, whereas vaginoscopy may be needed ifureter empties into vagina.

    • Neurologic Disorders

    Mental Retardation

    Although children with mild mental retardationmay have voluntary control of urination, they may have incontinencefor behavioral reasons, while those with severe retardation usuallylack voluntary control of urination.

    Neurogenic Bladder

  • Lower extremityweakness, gait disturbance, fecal incontinence, decreased or absent perianalsensation, and lack of normal anal sphincter tone are common findingsin children with neurogenic bladder.
  • Bladder size can be small, normal,or large, but usually it is small with thick wall.
  • Evaluation of urinary tract may includerenal U/S, voiding cystourethrography, and urodynamic testing.
  • Spinal dysraphism, a common cause ofneurogenic bladder in children, includes myelomeningocele, congenitaldermal sinus, diastematomyelia, and tethered cord syndrome.

  • Myelomeningoceleand dermal sinus tract are visible on physical exam.
  • Diastematomyelia is the splitting ofspinal cord at 1 or more vertebral levels, usually by bony or fibrousspur in spinal canal. The bone spicule may be detectable on spineradiography, but MRI is definitive imaging procedure.
  • Tethering of spinal cord maintainsabnormally low position of cord and prevents its normal ascent.Lipoma, dermoid cyst, or dermal sinus tract are associated lesions,and MRI is diagnostic.
  • Other causes of neurogenic bladderare sacral agenesis, spinal cord injury, and spinal cord tumors.
  • Failure to palpate sacrum and coccyxsuggest sacral agenesis. Radiography of lumbosacral spine showsabsence of sacral segments.
  • History of trauma exists with spinalcord injury.
  • Tumors affecting spinal cord are discussedin Chap. 5, Back Pain.

    • Abdominal or Pelvic Mass

    Abdominal or pelvic mass (fecal impaction,mesenteric cyst, presacral teratoma) that impinges on bladder cancause urinary incontinence during running, laughing, coughing, orlifting. Abdominal or pelvic U/S is most useful screeningtest.

    Polyuria

  • Childrenwith diabetes mellitus may have incontinence, especially at night,if they have persistent hyperglycemia that is difficult to control.Other causes of polyuria are diabetes insipidus and psychogenicpolydipsia.
  • Diabetes insipidus is associated withdefect in urine-concentrating ability. Random sample of urine withspecific gravity of >1.028 rules out concentration defect.Even specific gravity of >1.020 on random or early-morningurine sample is evidence of good concentrating ability and againstconcentrating defect.
  • Children with persistent polyuria mayhave structural and functional changes in bladder, which contributeto voiding dysfunction.
  • See Chap.47, Polyuria and Polydipsia.

    • Primary Psychologic Disturbance

    Urine incontinence occurs in some childrenwith primary psychologic problems (e.g., depression, a severe personalityor behavioral disorder, or psychosis). History, physical exam, clinicalobservation, and psychologic testing are diagnostic.

    Diagnostic Approach

  • Thoughtfullistening to parents and child usually reveals maturational, stress-related, orother psychologic factors that contribute to urinary incontinence.
  • History, physical exam, UA (includingmeasurement of specific gravity), and urine culture screen for organicdisorders and are helpful in pinpointing the cause of urinary incontinence.Physical exam should include observation of any gait disturbance,exam of sacrum, and testing of perianal sensation, anal sphinctertone, and lower extremity strength, sensation, and reflexes.
  • Abdominal U/S is useful forsuspected lower urinary tract obstruction, ectopic ureter, and abdominalor pelvic mass. Urinary urodynamic testing helps distinguish varioustypes of dysfunctional voiding disorders. CT and MRI are usefulin diagnosis of lesions that cause neurogenic bladder.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Polyuria and Polydipsia: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Diabetes Mellitus

  • By far,most common cause of polyuria and polydipsia in pediatric populationis diabetes mellitus.
  • Most common form is insulin-dependentdiabetes mellitus (type 1), in which autoimmune destruction of betacells of pancreas causes diminished insulin secretion and hyperglycemia.Subsequent glucosuria produces osmotic diuresis with polyuria, polydipsia,and polyphagia.
  • Second form is non–insulin-dependentdiabetes mellitus (type 2), which is characterized by insulin resistanceand usually relative insulin deficiency.
  • Criteria for diagnosis of diabetesmellitus have been established by American Diabetes Association(1999) and include symptoms of diabetes mellitus plus plasma glucoseconcentration ≥200 mg/dL at any time of day regardlessof time of last meal or fasting plasma glucose concentration ≥126 mg/dL(fasting is defined as no caloric intake for ≥8 hrs).

    • Diabetes Insipidus

  • 2 formsof diabetes insipidus are antidiuretic hormone (ADH) deficiencyand ADH resistance.
  • Primary clinical manifestations arepolyuria and polydipsia. Episodes of hypernatremic dehydration withhypotonic urine also may occur.

    • Antidiuretic Hormone Deficiency (Central Diabetes Insipidus)

  • Kidney isunable to conserve water with ADH deficiency because of absenceor lack of release of ADH (arginine vasopressin).
  • Genetic transmission of primary formis autosomal-dominant, and gene locus has been mapped to chromosome20p13.
  • Secondary form includes lesions thatdamage neurohypophyseal system: head trauma, infection (meningitis,encephalitis), tumors (most commonly craniopharyngioma), Langerhanscell histiocytosis, and metastatic neoplasia (leukemia).
  • Specific gravity of morning urine specimenshould be ≥1.018 in normal children without any overnight fluidintake. Presence of inappropriately dilute urine with hyperosmolarserum suggests ADH deficiency, and water deprivation test shouldbe performed under controlled supervised conditions.
  • Inability to concentrate urine by waterdeprivation and resolution with administration of exogenous argininevasopressin confirm diagnosis.

    • Antidiuretic Hormone Resistance (Nephrogenic Diabetes Insipidus)

  • The defectin this form of diabetes insipidus is inability of renal tubuleto respond to ADH.
  • Primary form is usually due to X-linkeddisorder with defect in vasopressin receptor; however, autosomal-dominantand -recessive forms also occur.
  • Secondary form is due to several disorders(renal dysplasia, medullary cystic disease, cystinosis, sickle celldisease, chronic renal failure, Fanconi syndrome, Bartter syndrome,hypercalcemia) and drugs (lithium, demeclocycline, methoxyflurane,amphotericin B, phenytoin) that produce renal concentrating defects.

    • Primary Polydipsia

  • Is the excessiveingestion of water, when it is not needed to maintain fluid balance.
  • Causes include compulsive water drinkingfor psychological reasons and frequent presentation of fluids toinfants. Another cause of primary polydipsia is hypothalamic damagethat affects thirst center but not ADH release.
  • When overnight fluids are withheld,concentrated urine can be produced in the morning. Serum vasopressinlevels are low but increase to normal with fluid deprivation.

    • Diagnostic Approach

  • Polyuriamust be distinguished from small volume urinary frequency, whichis common in pediatric practice. Children with polyuria often havenocturia and are unable to sleep through the night without wakingup to urinate. Most children with urinary frequency do not havepolyuria or a defect in urinary concentrating ability. Common causesof isolated urinary frequency are habit, attention-seeking behavior,and urinary tract infection.
  • Random sample of urine with specificgravity of >1.028 and absence of polyuria rules out a concentrationdefect. Even urinary specific gravity of >1.020 on randomor early morning sample indicates sufficient urinary concentrationsuch that symptomatic diabetes insipidus is unlikely. Children whohave urine with a somewhat lower than normal specific gravity butwho can sleep through the night without passing urine do not needfurther evaluation.
  • Presence of polyuria, dehydration,and high urinary specific gravity is evidence for osmotic diuresis,which is most commonly caused by diabetes mellitus. Dilute urineassociated with polyuria suggests diabetes insipidus or psychogenicpolydipsia. If blood glucose and urea nitrogen are normal, high serumosmolality with hyposmolar urine suggests ADH deficiency or resistance.Low serum osmolality with hyposmolar urine suggests primary polydipsia.
  • With either ADH deficiency or resistance,urine specific gravity rarely exceeds 1.005 and urinary osmolalityrarely exceeds 200 mOsm/kg. Water deprivation test thatdemonstrates inability to concentrate urine indicates diabetes insipidusand distinguishes it from primary polydipsia. If urine remains hypotonicwith dehydration, next step is to determine response to exogenousvasopressin, which distinguishes ADH deficiency from resistance.With ADH deficiency, administration of vasopressin causes diminishingof symptoms and increase in urine specific gravity, whereas no responseoccurs with ADH resistance.
  • With suspected renal disease, certaintests should be performed: CBC and differential; UA; urine culture;serum electrolytes, calcium, phosphorus, and creatinine; blood ureanitrogen; hemoglobin electrophoresis; and renal U/S. Othertests (e.g., determination of serum and urinary amino acids, voiding cystourethrography,and renal biopsy) may be necessary to define specific renal abnormality.
  • Psychosocial history of emotional disturbance,including episodes of compulsive water drinking and formation ofconcentrated urine with fluid deprivation, are evidence for psychogenicpolydipsia. This disorder may sometimes be difficult to distinguishfrom hypothalamic thirst defect, and consultation with a pediatricendocrinologist is recommended.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Dysuria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?

    Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and the use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.

    During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Oliguria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).

    Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.

    Begin the physical examination by taking the patient's vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.

    Obtain a urine specimen and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Polyuria: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Because the patient with polyuria is at risk for developing hypovolemia, evaluate his fluid status first. Take his vital signs, noting an increased body temperature, tachycardia, and orthostatic hypotension (a 10 mm Hg decrease in systolic blood pressure upon standing and a 10 beats/minute increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration. Is the patient unusually tired or thirsty? Has he recently lost more than 5% of his body weight? If you detect these effects of hypovolemia, you'll need to infuse replacement fluids.

    If the patient doesn't display signs of hypovolemia, explore the frequency and pattern of the polyuria. When did it begin? How long has it lasted? Was it precipitated by a certain event? Ask the patient to describe the pattern and amount of his daily fluid intake. Check for a history of visual deficits, headaches, or head trauma, which may precede diabetes insipidus. Also check for a history of urinary tract obstruction, diabetes mellitus, renal disorders, chronic hypokalemia or hypercalcemia, or psychiatric disorders (past and present). Find out the schedule and dosage of any drugs the patient is taking.

    Perform a neurologic examination, noting especially any change in the patient's level of consciousness. Then palpate the bladder and inspect the urethral meatus. Obtain a urine specimen and check its specific gravity.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary frequency: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient how many times per day he voids. How does this compare with his previous pattern of voiding? Ask about the onset and duration of the abnormal frequency and about any associated urinary signs or symptoms, such as dysuria, urgency, incontinence, hematuria, discharge, or lower abdominal pain with urination.

    Ask also about neurologic symptoms, such as muscle weakness, numbness, or tingling. Explore his medical history for urinary tract infection, other urologic problems or recent urologic procedures, and neurologic disorders. With a male patient, ask about a history of prostatic enlargement. If the patient is a female of childbearing age, ask whether she is or could be pregnant. Obtain a complete drug history.

    Obtain a clean-catch midstream specimen for urinalysis and culture and sensitivity tests. Then palpate the patient's suprapubic area, abdomen, and flanks, noting any tenderness. Examine his urethral meatus for redness, discharge, or swelling. In a male patient, the physician may palpate the prostate gland.

    If the patient's medical history reveals symptoms or a history of neurologic disorders, perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary hesitancy: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed hesitancy and if he has ever had the problem before. Ask about other urinary problems, especially reduced force or interruption of the urine stream. Ask if he has ever been treated for a prostate problem or UTI or obstruction. Obtain a drug history.

    Inspect the patient's urethral meatus for inflammation, discharge, and other abnormalities. Examine the anal sphincter and test sensation in the perineum. Obtain a clean-catch specimen for urinalysis and culture. In a male patient, the prostate gland requires palpation. A female patient requires a gynecologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary incontinence: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.

    Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.

    After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urinary urgency: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient about the onset of urinary urgency and whether he has ever experienced it before. Ask about other urologic symptoms, such as dysuria and cloudy urine. Also ask about neurologic symptoms, such as paresthesia. Examine his medical history for recurrent or chronic UTIs or for surgery or procedures involving the urinary tract. Obtain a complete drug history.

    Obtain a clean-catch specimen for urinalysis and culture. Note urine character, color, and odor, and use a reagent strip to test for pH, glucose, and blood. Then palpate the suprapubic area and both flanks for distention and tenderness. If the patient's history or symptoms suggest neurologic dysfunction, perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urine cloudiness: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent UTIs or recent surgery or treatment involving the urinary tract. Obtain a complete drug history.

    Obtain a urine specimen to check for pus or mucus. (See Performing the three-glass urine test, page 613.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.

    If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, barking: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, nonproductive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

    As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

    Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

    Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, productive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

    Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds—rhonchi, crackles, or wheezes.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    COUGH: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. Postnasal drip from chronic sinusitis should be ruled out. An allergic history (e.g., hay fever) is important. Cardiovascular disease should be carefully excluded, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    DYSURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes a urinalysis, urine cultures, smear and culture of any discharge, an IVP, voiding cystogram and cystoscopy, and cystometric examination. In women with “negative” cultures, Chlamydia urethritis must be considered and treated. In men with negative cultures, prostatic examination, massage, and evaluation of discharge are done. Massage of the prostate should be avoided in acute prostatitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    POLYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of polyuria depends largely on the association of other symptoms. Polyuria, polyphagia, and polydipsia suggest diabetes mellitus and hyperthyroidism. Polyuria with only polydipsia suggests psychogenic or idiopathic diabetes insipidus; the Hickey–Hare test will differentiate the two. Polyuria with polydipsia and weakness but with no significant weight loss suggests hypercalcemia and possible hyperparathyroidism. Chronic nephritis will be diagnosed by examination of the urine sediment and a specific gravity that remains at 1.010. Nephrogenic diabetes insipidus can be differentiated from neurogenic diabetes insipidus by the inability of the kidney to respond to a pitressin injection.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PROTEINURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The first step is to determine whether the proteinuria is caused by infection. A urinalysis for WBCs and examination of a fresh drop of unspun urine under the microscope for the bacteria are the fastest ways of determining this. The urine can also be cultured. Next, determine if there are red cells in the urine. This would indicate a more serious cause for the proteinuria such as collagen disease, stone, glomerulonephritis, or neoplasm and prompts the need for an IVP, cystoscopy, and urology consult.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PYURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    How does one track down the cause of pyuria? First, it must be determined that the cloudy urine is really pyuria. Amorphous phosphates and other inert material will disappear on treating the urine with dilute acetic acid. Then, just as for other nonbloody discharges, one must do a smear and culture for the offending organism; an examination of the urine, especially the unspun specimen, is axiomatic. If one finds clumps of leukocytes, renal gitter cells, or WBC casts, the infection almost certainly comes from the kidney. Motile bacteria in an unspun specimen examined under high-power microscopy and a colony count of over 100,000 per mL signify infection. A three-glass test may be helpful in localizing the site of origin of the pyuria. Anaerobic cultures and cultures for Chlamydia may be needed. Look for eosinophils on a Wright stain of the urine if toxic nephritis is suspected. Vaginal examination and culture may disclose a source for the infection. In the male, one episode of pyuria should be sufficient indication for an IVP; a female should have one after her second episode, especially if no cause can be found on physical examination. Cystoscopy and a voiding cystogram are often indicated at this time.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ANURIA AND OLIGURIA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis). The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine; if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography after the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also. The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal azotemia, the BUN/creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN/creatinine ratio will be 10:1 or less. Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his or her anuria, and a urologist should be consulted. Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, a serum haptoglobin test should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer, or lupus erythematosus cell prep. A renal biopsy may also be necessary in these and many other disorders.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    INCONTINENCE, URINARY: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    First, exclude stress incontinence with a pad test. Perineal pads are weighed before and after walking and stress for 30 minutes. An increase in weight identifies urine loss. Catheterization and examination, smear, and culture of the urine are essential at the outset. Cystoscopy and cystometric studies are often needed. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and propantheline bromide (ProBanthine), a parasympatholytic drug, for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Urinary Tract Infections: Diagnosis
    (Pediatric Infectious Disease)

    Paramount to the diagnosis of urinary tract infection and any subsequent radiographic investigation is proper collection and examination of the urine. A bagged specimen is not appropriate for the diagnosis of urinary tract infection because it is easily contaminated by bacteria. In infants who are in diapers, an “in-and-out” catheterization is usually required. In toilet-trained children, a clean-catch specimen may be adequate if the child can be adequately prepped. Urine specimens that cannot be processed at once should be refrigerated at 4 °C. Urine kept at room temperature, for even a short period of time, can alter the results of leukocyte esterase and nitrate tests routinely done on dipstick examination.

    Analysis of a properly obtained urine specimen can provide a clue to the presence of infection. However, there remains considerable debate about the best test to perform. Urine dipstick for nitrate and leukocyte esterase, evaluation for bacteruria, and the presence of pyuria have all been used as screening tests for urinary tract infections.

    Nitrate detected by dipstick is positive in 50% of children with urinary tract infection. This relatively low figure may be related to the fact that the test requires bacteria to remain in the bladder for several hours, a condition that is less likely in children.

    The evaluation for pyuria is complicated by a variety of factors, including the precise number of white blood cells needed for presumptive diagnosis of infection and whether the urine specimen being evaluated is centrifuged before analysis. Hemocytometry is a method used to count white blood cells in body fluids such as spinal fluid and urine. In recent years, considerable study has been done on the use of hemocytometry in “enhanced urinalysis.” In this method, urine is obtained by catheter and evaluated as an uncentrifuged specimen. The enhanced urinalysis is considered positive if there are more than 10 white blood cells/mm 3 and any bacteria on Gram stain. The sensitivity of this method is 85%, with a specificity of 99%. The drawback to enhanced urinalysis is that the equipment needed may not be readily available. The traditional standard urinalysis uses centrifuged specimens, with pyuria being defined as at least 5 white blood cells per high-power field and the presence of any bacteria. The sensitivity of this method is 65%, with 92% specificity.

    In 1999, the American Academy of Pediatrics recommended dipstick evaluation, standard microscopy, and Gram stain as useful screens for urinary tract infection. Positive leukocyte esterase or nitrate on dipstick, greater than 5 white blood cells per high-power field on standard urinalysis, or a positive Gram stain of unspun urine is suggestive of urinary tract infection. These parameters continue to be evaluated, with some investigators commenting on the need to evaluate further the screening methods or even to eliminate urinalysis entirely. It should be understood that urine testing serves as a screen. A negative screen does not rule out urinary tract infection. Clinical correlation is always needed. In a febrile child who has a strong possibility of urinary tract infection, a negative urinalysis should be followed by a urine culture.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Infectious Disease, 2004


     » Next page: Signs of Urinary tract infections (child)

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