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Diagnostic Tests for Urinary tract infections (child)

Contents
  1. Urinary tract infections (child): Introduction
  2. Tests for Urinary tract infections (child)
  3. Symptoms of Urinary tract infections (child)
  4. Diagnosis
  5. Home Diagnostic Testing
  6. Complications

Urinary tract infections (child): Diagnostic Tests

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

Urinary tract infections (child) Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Urinary tract infections (child):

Urinary tract infections (child) Diagnosis: Book Excerpts

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

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Urinary tract infections (child).

COUGH: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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).

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.)

» READ BOOK EXCERPT ONLINE »

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

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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).

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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

 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).

Testing

A. Clinical laboratory tests. Most acute presentations of cough do not require blood, urine, or other laboratory tests. White blood count with differential and blood cultures are indicated for pneumonia. Gram’s stain and culture of sputum are rarely practical in the office. A purified protein derivative (PPD) test should be placed early if TB is suspected, unless the patient is known to be anergic or thought to have overwhelming active TB disease. Systemic causes require testing specific to the disease in question.

B. Radiologic tests. A chest x-ray study is not indicated for upper respiratory causes or bronchitis. It is only useful when pneumonia, TB, COPD, CHF, or cancer (primary or metastatic) are being considered. Computed tomography of the sinuses is more sensitive and specific than PE to differentiate sinusitis from other causes of cough.

C. Pulmonary function tests. The simple peak flow meter used with a therapeutic trial of bronchodilators will identify most cases of asthma. This important test should be supervised by the physician or an experienced nurse. Additional testing is suggested for COPD and pulmonary fibrosis.

D. Invasive tests. Bronchoscopy is useful for foreign body aspiration, cancer, or chronic interstitial lung disease. Esophageal pH monitoring will most likely confirm suspected GERD.

Diagnostic assessment

A thorough history is vital to accurate diagnosis. Acute cough is likely to be infectious. A pertinent observation is that physicians overtreat acute bronchitis with antibiotics. The literature suggests that most cases are viral in origin and antibiotics are ineffective. Chronic cough has a longer list of differential diagnoses. Asthma tends to be underdiagnosed in adults and children. Smoking-related causes should prompt educational intervention and workup, especially in older patients. GERD is a diagnosis often missed because it is not considered. Often, more than one office visit is needed to unravel the cause of chronic cough. Up to 80% of cases have multiple causes (5). Making an accurate diagnosis is essential to successful treatment. Of cough presentation, 90% can be adequately managed in the family physician’s office, although it can take 3 to 5 months to arrive at a correct diagnosis in some cases (2). Referral to a pulmonary specialist is needed only in complicated cases (e.g., cancer, occupational and connective tissue diseases, and failed therapy).


References

1. Weiss BD. 20 common problems in primary care. New York: McGraw-Hill, 1999.

2. Lawler WR. An office approach to the diagnosis of chronic cough. Am Fam Physician 1998;58(9):2015–2022.

3. Heath JM. Chronic bronchitis: primary care management. Am Fam Physician 1998;57(10):2365–2372, 2376–2378.

4. Irwin RS. Managing cough as a defense mechanism and as a symptom. A consensus report of the American College of Chest Physicians. Chest 1998;114:133S–181S.

5. Irwin RS. Silencing chronic cough. Hosp Pract 1999;34:53–60.>

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

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

 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.

Testing

The history and physical examination usually suggests which tests are most appropriate. A urinalysis is the most common study performed. It is important also to gather samples for gonorrhea, chlamydia, and HSV, using wet preparations and potassium hydroxide testing when appropriate. Rapid tests on urine samples for the detection of bacteria and leukocytes can be done while patients wait. Direct microscopic examination of the urine can isolate bacteria and leukocytes. Rapid dipstick biochemical tests can isolate leukoesterase and nitrate, which are consistent with leukocytes and urea-fixing bacteria. Urine cultures require overnight to 48 hours of incubation to detect specific bacterial pathogens. Pyuria (defined as white blood cell count >10/mm3 of urine) is seen in more than 95% of patients with acute UTI but is uncommon in the absence of infection. Pyuria without bacteriuria suggests a chlamydia infection. Urine dipstick testing is generally less sensitive for pyuria than microscopic examination, but it is more convenient (5).

Diagnostic assessment

Given the many causes of dysuria, an accurate diagnosis can be difficult without a thorough approach to each patient. Because most causes have other associated symptoms and findings, a diagnosis can usually be made with a carefully taken history, a focused physical examination, and appropriate laboratory tests. Separating an uncomplicated UTI or STD from the more serious pyelonephritis and other possible diagnoses is the challenge in these patients.


References

1. Carlson KJ, Mulley AG. Management of acute dysuria. Ann Intern Med 1985;102:
244–249.

2. Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract infections. Infect Dis Clin North Am 1987;4(1):773–791.

3. Ainsworth JG, Weaver T, Murphy S, Renton A. General practitioners’ immediate management of men presenting with urethral symptoms. Genitourin Med  1996;72(6):427–430.

4. Roberts RO, Lieber MM, Rhodes R, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998;51(4):578–584.

5. Kurowiski K. The woman with dysuria. Am Fam Physician 1998;57(9):2155–2164, 2169–2170.

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

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

 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.

Testing

 A. Voiding journal. A voiding journal is a good way to get additional information about the patient’s problem. Have the patient record the time and approximate amount of each voiding, and whether they were wet or dry.

 B. Urinalysis. Be cautious when interpreting the urine analysis: in the absence of other symptoms, bacteriuria is seldom the primary cause of UI. Treat cystitis or urethritis when the rest of the clinical picture confirms them. Unexplained, persistent microhematuria requires investigation (Chapter 10.2).

 C. Postvoiding urine volume. The patient should be catheterized immediately after voiding. In general, the postvoid urine volume should be less than 50 ml. Volumes in the range of 100 to 200 ml may suggest impaired bladder contractility or obstruction. Volumes greater than 200 ml strongly suggest obstruction.

D. Blood urea nitrogen, creatinine, and glucose are simple blood tests that help rule out underlying renal disease and diabetes.

 E. Special tests are available via urologic consultation to further delineate the cause of UI. These include cystoscopy, cystometry, and other voiding studies. Up to two-thirds of patients can be successfully treated without urologic referral.

Diagnostic assessment

 The clinical history is the most important factor leading to the correct diagnosis and successful treatment of urinary incontinence. However, it is an imperfect tool at best. In one review, clinical history had a sensitivity and specificity for stress incontinence of 0.90 and 0.50, respectively. For detrusor instability, the figures were 0.74 and 0.55 (2).

The task becomes even more problematic when considering the reluctance of patients to talk about their symptoms and the tendency for UI to be of a mixed type. Response to therapy (or lack thereof) often drives the practical management of this condition. Lack of response to multiple trials of therapy is a good indication for consulting a urologist. Remember, that your initial assessment will often be incorrect, so keep an open mind and consider all possible diagnoses. Finally, recall that UI frequently involves more than one causal factor. For example, many elderly people have a functional component (can’t get to the toilet quickly) in addition to one of the other types.


References

1. Urinary incontinence in adults: acute and chronic management. AHCPR Clinical Practice Guideline, No. 2 (1996 Update) Accessed August 1999; http://text.nlm.nih.gov/
ftrs/gateway/

2. Jensen JK, Nielsen FR, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83(5):904–910.

3. Finding out about incontinence. AAFP Patient Information Handout (1998) Accessed August 1999; http://www.aafp.org/patientinfo/incont.html

4. Goode PS, Burgio KL. Pharmacologic treatment of lower urinary tract dysfunction in geriatric patients. Am J Med Sci 1997;314(4):262–267.

5. Weiss BD. Diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Physician 1998;57(11):2665–2687. Accessed August 1999; http://www.aafp.org/afp/
980600ap/weiss.html

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

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

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.

Testing

 A. An indwelling urinary catheter serves as a diagnostic tool (if obstruction has occurred at the bladder neck or urethra) and for accurate urine volume measurement. Urine output and blood pressure monitoring can often lead to expedient correction of prerenal causes, thus avoiding further complications.

 B. Urinalysis is often normal in prerenal causes of oliguria or anuria, except being highly concentrated with possible qualitative proteinuria because of the high concentration. Microscopic analysis is usually unremarkable (or reveals few hyaline or granular casts) in prerenal causes; whereas proteinuria, casts, and hematuria can point to renal causes.

 C. Urine osmolality is typically high in prerenal causes (>500 mOsm/kg H2O) versus impaired in renal causes (<350 mOsm/kg H2Ο) (2).

D. Urine sodium is typically less than 20 mEq/L in prerenal causes (unless diuretics have been used) versus more than 40 mEq/L in renal causes (2).

E. Blood urea nitrogen and creatinine levels are elevated. The ratio must be interpreted considering the entire clinical situation. Urine:plasma creatinine ratio (U:P Cr) is calculated to help differentiate between prerenal (U:P Cr >40) and renal (U:P Cr <20) causes (2).

F. Diagnostic imaging, which may be necessary in some cases, is guided by the history and PE findings [e.g., ultrasound (US), computed tomography (CT), retrograde pyelogram, renal biopsy].

Diagnostic assessment

The key to a diagnosis of oliguria or anuria is to actively anticipate when it is likely to manifest and accurately measure using an indwelling catheter. Once recognized and a cause is suggested, (a) prerenal causes can be assessed further by measuring hemodynamic status and administering fluids; (b) renal causes can be assessed further with urinalysis (qualitative and quantitative), renal US, or renal biopsy; and (c) postrenal causes can be assessed further using US, CT, or retrograde pyelography.


References

1. Eliahou HE. Oliguria and anuria. In: Massry SG, Glassock RJ, eds. Massry and Glassock’s textbook of nephrology, 3rd ed. Baltimore: Williams & Wilkins, 1995:543–546.

2. Lake EW, Humes HD. Acute renal failure including cortical necrosis. In: Massry SG, Glassock RJ, eds. Massry and Glassock’s textbook of nephrology, 3rd ed. Baltimore: Williams & Wilkins, 1995:984–987.>>>>

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

Dysuria: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Polyuria: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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).

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Source: Field Guide to Bedside Diagnosis, 2007

Proteinuria: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Urinary Incontinence: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Anuria/Oliguria: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

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

Ask the patient to void before beginning your examination. Inspect the urethral meatus for discharge, irritation, and other abnormalities. Then percuss over the kidneys. Costovertebral angle tenderness indicates kidney inflammation. Percuss the bladder. Start at the symphysis pubis and percuss upward. You should hear tympany; a dull sound signals retained urine. Then palpate the kidneys. Normally, they aren’t palpable unless they’re enlarged. If the kidneys feel enlarged, the patient may have hydronephrosis, cysts, or tumors. You won’t be able to palpate the bladder unless it’s distended. (See Palpating the kidneys.) A pelvic or rectal examination may be necessary.

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

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

Begin the physical assessment 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.

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

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

Take vital signs, noting increased body temperature, tachycardia, and orthostatic hypotension (a 10 mm Hg or greater decrease in systolic blood pressure upon standing and a 10 beats per minute or greater increase in heart rate upon standing). Inspect for dry skin and mucous membranes, decreased skin turgor and elasticity, and reduced perspiration.

Perform a neurologic assessment, 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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

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

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 assessment.

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

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

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.

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

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

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

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

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 assessment.

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

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

Observe the child for signs of respiratory distress. Note use of sternal or intercostal retractions or nasal flaring. Observe his skin for cyanosis and diaphoresis. Take his vital signs, noting respiratory rate and depth. Although stridor can be heard without a stethoscope, auscultate his lungs. Decreased breath sounds and crackles may be present.

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

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

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 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, and 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 rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

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

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

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 pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

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

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

  • 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.

    • » READ BOOK EXCERPT ONLINE »

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

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

    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.

    » READ BOOK EXCERPT ONLINE »

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

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

  • 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.

    • » READ BOOK EXCERPT ONLINE »

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

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

  • 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.

    • » READ BOOK EXCERPT ONLINE »

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

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

  • 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


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

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