OSCE Flashcards
Haematuria history HPC
HPC == CLots
- CLarify exactly when, colour, beetroot?
- Onset when did you first notice it
- Timing always there or come and go
- Severity do you pass any clots
Haematuria history associated symptoms
Associated symptoms
- Pain == SOCRATES
- Frequency , has this changed do you have sudden urge
- Nocturia
- Urinary stream
- Constitutional , any general unwellness
- Renal failure , gained weight, swollen ankles
- Glomerulonephritides, sore throat, rashes, joint ache
- Pulmonary- renal conditions , coughed up blood
- Trauma , stomach, groin trauma
ICE
Haematuria history SHX, PMH, DHX etc
PMH
- UTI, prostate renal bladder cancer
- BPH
- Diabetes
- HTN
- Catheter
Drug history
- Any regular meds
- Allergies
Family history
- Renal disease
- PKD
- Haematuria
SHX
- Smoke
- Worked with industrial chemicals or dyes
Important points haematuria
Always clarify colour
Clots = unlikely to be glomerular cause
Always clarify timing (initial, middle, terminal)
Poor stream suggests obstruction
Haematuria DDX considerations
Gross or microscopic
Gross- tends to be lower lesion higher likelihood of malignancy so investigated more vigorously
Microscopic is more common and only warrants further investigation if recurring or associated with UTI symptoms
Haematuria DDX Carcinoma
Renal cell carcinoma
- triad of flank pain, haematuria and abdominal mass
- constitutional symptoms
- May present with paraneoplastic syndrome excess renin, parathyroid hormone and EPO
TCC
- Painless intermittent haematuria in older males, worrying sign
- Working with industrial dyes, smoking
- Schistosomiasis
Haematuria DDX renal calculi
Renal calculi
- Classic acute excruciating pain radiates from loin to groin, with N&V
- Men in 30’s- 50’s
- Pain is more constant than biliary colic, but can have period of dull ache
- Most cases are actually found asymptomatically
Haematuria DDX UTI
Cystitis
- typically urinary frequency, urgency and pain
- fever
- urethral discharge
- Cloudy and foul odour urine
- More common in women and elderly, may just have delirium
Haematuria DDX glomerulonephritis
Many different causes may have preceding URTI, streptococcal nephropathy IgA nephropathy Haemoptysis - Goodpastures Rash and systemic features- vasculitis
Management haematuria
frank haematuria requires urgent referral to urology
bladder cancer = transurethral resection for superficial tumours
RCC- nephrectomy
Renal calculi - < 5mm usually pass on own, extracoporeal lithotripsy or endoscopic removal for medium stones
Nephrotic syndrome- treat cause eg furosemide, acei ccb to control fluid retention
Rapidly progressive glomerulonephritis, high dose steroids and cyclophosphamide
Dysuria HPC and urinary history
o’ SOCRATES
Frequency - and volume passed Urgency Colour, blood Discharge, colour, volume, smelly= sexual history Fever
Urological history men and women
Men
- Urinary stream , start, power, dribbling
- Nocturia
- Prostatitis- ejaculation painful?
Women
- Menopause?
- Dysmenorrhoea
Dysuria abdo history
Abdo pain - socrates
Calculi - stones?
Painful bowel motions
Diarrhoea
Dysuria PMH, SHX, DH etc
PMH
- UTI, STI, renal calculi
- arthritis and conjuctivitis
- Catheter
DH
- Medications
- allergies
SHX
- does your partner have any similar symptoms
- Occupation
- Smoking and drinking
Dysuria overview
o SOCRATES urinary history male/female abdo PMH etc
Haematuria overview
HPC clots
Associated symptoms
PMH etc
Dysuria important points
Always tailor history to the individual eg 20 yo vs 60 yo
Pain at start suggests urethritis
Pain at the end suggests cystitis
DDX dysuria UTI
Cystitis
- typically urinary frequency, urgency and pain
- fever
- urethral discharge
- Cloudy and foul odour urine
- More common in women and elderly, may just have delirium
DDX dysuria pyelonephritis
Very unwell, fever rigors nausea and vomiting flank pain radiates to the back
Dysuria, frequency, urgency etc may be present
DDX dysuria STI
discharge common
history of new partner or unprotected sex
history of painful sex, painful ejaculation, prostatitis
Symptoms of reactive arthritis
DDX dysuria endometriosis
Cyclical pelvic pain which crescendos before menstruation and then dissipates
Dyspareunia, dysmenorrhoea, subfertility
DDX dysuria renal calculi
Renal calculi
- Classic acute excruciating pain radiates from loin to groin, with N&V
- Men in 30’s- 50’s
- Pain is more constant than biliary colic, but can have period of dull ache
- Most cases are actually found asymptomatically
DDX dysuria BPH
Urinary frequency and nocturia with obstructive symptoms = hesitancy, weak stream and dribbling
Incomplete bladder emptying causes continuous urge to go
Dysuria secondary to UTI due to urinary stasis
Dysuria management
UTI - trimethoprim
Pyelonephritis - antibiotics
STI - refer to GUM give one off AB and start contact tracing
BPH - alpha blockers to relax sphincters and 5 alpha reductase inhibitor (reduce androgen ADT)
Polyuria HPC
Urinary history
- Onset
- frequency
- Nocturia
- Amount
- Thirst
- Dysuria
- Haematuria and discharge
- Urge incontinence
Polyuria urological history men and women
Men
- urinary stream
- prostatitis ejaculation and defaecation pain
Women
- Prolapse, dropping sensation from pelvis, anything protruding
- Obstetric history complicated, large?
- Menopause
Polyuria endo history
Abdo pain if so SOCRATES
Constitutional, weight loss, appetite, fever etc
Polyuria PHM etc
PMH
- diabetes
DH
- diuretics
- allergies
FH
- diabetes
- renal conditions
SHX
- smoke
- drink
- alcohol
Polyuria overview
Urinary history
Urological history men/women
endo
PMH etc
Polyuria important points
Polyuria is defined clinically as production of more than 3L urine in 24 hours this is very difficult to measure so may be best using a voiding diary
Polyuria DDX UTI
dysuria, frequency and urgency
fever and discharge
may be frothy with foul odour, may contain blood
often in women and elderly with only delirium as presenting complaint
Polyuria DDX hyperactive bladder
severe urgency, nocturia, incontinence and frequency
Past history of neurological disease, eg Parkinsons, stroke, spinal cord disease
Genitourinary prolapse
older women
multiple vaginal deliveries
hysterectomy
frequency, recurrent UTIs, stress incontinence, fullness sensation in vagina
Polyuria DDX BPH
frequency, nocturia and hesitancy = ( weak stream, trouble starting and terminal dribbling)
incomplete bladder emptying gives continuous urge to go
Polyuria DDX Diabetes mellitus
Polydipsia, polyuria, abdominal pain, nausea and vomiting, pear drop breath in DKA
Often family history
Polyuria DDX Diabets insipidus
Polydipsia and polyuria
Huge quantities of very dilute urine
Nocturia often present and bothersome
No signs of infection, irritative disorder
Polyuria DDX
UTI vaginal prolapse Diabetes M Diabetes I Hyperactive bladder BPH
Haematuria DDX
Renal cell carcinoma Transitional cell carcinoma Renal calculi UTI Glomerulonephritis
Dysuria DDX
UTI Pyelonephritis BPH STI Endometriosis Renal calculi
Polyuria Management
Diabetes M- diet or insulin
Diabetes I - careful regular fluids, step up to exogenous ADH
DKA- fluid and electrolyte resus insulin until glucose level is controlled
Genitourinary prolapse - vaginal pessaries, surgery to tighten up ligaments
Hyperactive bladder- pelvic floor exercises, cut out caffeine and alcohol, botox if refractory
Diuretics- take in morning if have to
Male genital exam steps
General inspection
- skin, eyes, joints
- lower abdomen, femoral and inguinal (bear down), scrotum bear down.
Palpation standing
- scrotum bear down and lumps swellings
Palpation supine
- testicle size, surface, mobility
- epididymis
- vas deferens
- lumps/mass, palpate, tender, impulse, transillumabillity, cough impulse
- penis
- foreskin
- meatus
- frenulum
- corona
Lymph nodes
- inguinal, sub inguinal, medial thigh
Femoral pulses
Gyanecological exam steps
Intro
- ask allergies, emptied bladder
- position light, use latex free gloves
Inspection
- warts, ulcers, masses
- vulvitis
- prolapse, ask to bear down, and for stress incontinence
- discharge
- swelling
Bimanual palpation
- Lubricant
- behind cervix and push up while pushing down on abdomen, size, shape and position, mobility
- adnexae, masses and tenderness
- cervix, tenderness, polyps, masses, consistency, closed/open os
Speculum examination steps
Warm speculum
water/lubricant gel to speculum
Inspect vagina
- masses, swellings, warts, discharge
Cervix
- nulliparous, ectropion, masses, polyps
- nabothian cysts (ecto growing over endo)
- discharge
- bleeding
Swabs - take from endocervical and high vaginal
Smear test ALWAYS WARN ABOUT SPOTTING / SLIGHT BLEEDING AFTERWARDS
Male catheterisation equipment
apron sterile gloves catheter pack catheter collection bag 50ml syringe 10ml water Instillagel antiseptic fluid
Have smaller catheter nearby
2x bins
Male catheterisation steps
Intro
clean hands
position patient
put on apron
unpack catheter pack
put in catheter, syringe, water, collecting bag into sterile field
pour in antiseptic gel
wash hands
put on sterile gloves
Prepare equipment caps
Expose patient
put on sterile drape over penis hold penis with dirty hand, retract foreskin and clean with wipe
Insert anaesthetic instillagel and wait 5 mins
Introduce catheter tip and move in gradually with non touch technique
Once fully in check urine outflow push on bladder and use syringe if necessary
Inflate balloon
Attach catheter bag
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