Week 1 - Dysuria and fatigue

Question 1

Mrs. G.M. is a 57-year-old woman with longstanding type 2 diabetes.

Take a history of this patient.

HPC:
• Dysuria, puffy face, backache - 36h.
• Worsening fatigue, incontinence* - months.
• 3x UTI in last 5/12 (recurrent history of UTI).
• No haematuria, no fever, no loin pain (UTIs can present with no fever).
• BSL high 9-11, 2x hypo’s BSL 2.4.
• Back pain - h/o trauma, mild pain, on OTC ibuprofen. (Kidney can also be a cause of back pain).
• Severe fatigue, worsening diarrhoea, nausea, anorexia. (Features of uraemia - chronic renal failure).

• Urological history - SOCRATES for pain.
• ATSI.
• Post menopausal.
• Diabetes.

Answer 1

HPC:
• Change in appearance of urine (e.g. haematuria).
• Change in urine volume or stream - polyuria, nocturia, anuria, decrease in stream size, hesitancy, dribbling, urine retention, strangury, Pis-en-deux - double voiding (incomplete bladder emptying), incontinence of urgency.
• Renal colic.
• Dysuria (painful micturition).
• Frequency, urgency.
• Fever, loin pain.
• Uretheral discharge.

• Symptoms suggestive of CKD (uraemia):

• Oliguria, nocturia, polyuria.
• Anorexia, a metallic taste, vomiting, fatigue, hiccup, insomnia.
• Itch, bruising, oedema.
• Question box 17.1

• Menses:

• Age of onset.
• Regularity.
• Late period (date).
• Dysmenorrhoea, menorrhagia.
• Erectal dysfunction.
• Loss of libido.
• Infertilty.
• Pregnancies - number of any complications.
• Urethral or vaginal discharge.
• Generalised rash.

• Fatigue:

• Malignancy - weight loss, loss of appetite.
• Heart failure/anaemia - chest pain, dyspnoea.
• Depression - loss of interest in activities, low mood.
• Recent sore throat/skin infection.
• Diarrhoea, change in bowel habit.
• Sexual history.

PMHx:
• Past history of hypertension, diabetes, malabsorption syndromes, polycystic kidney disease.
• Autoimmune - vasculitic rash, sinusitis, nose bleeds, arthropathy, Sjogren’s syndrome.

PSHx:
• Any past surgeries or biopsy?

Medications:
• Any regular medications? i.e. OTC, herbal medications, NSAIDs, antibiotics, immunosuppressants, antihypertensives.
• Nephrotoxic drugs - gentamycin, NSAIDs, COX-2, ACE, radio contrast.

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, Pneumococcal.
• Pap smears, mammograms.

FHx:
• Family history of hypertension, diabetes, inherited forms of kidney disease.

SHx:
• Background
• Occupation i.e. heavy metal exposure.
• Education
• Religion
• Living Arrangements i.e. family support, impact of chronic disease, dialysis.
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: alert, oriented, wasting/cachexia, pain, distress, oedema. Signs related to DDx - heart failure, anaemia, malignancy, renal failure.

3. Vital signs: 
• HR
• BP
• Temp
• RR
• BMI

4. Hands: clubbing, nail changes related to deficiency/malabsorption e.g. leuconychia, Muehrcke’s lines.
5. Face: conjunctival pallor, pale mucous membranes, glossitis, angular stomatitis.
6. Neck: JVP.
7. CVS/RS
8. NEURO: diabetic neuropathy.

• Hyperventilation (acidosis)
• Statue, brown discolouration nails
• Skin - pallor, photosensitive pigmentation, sallow, scratch marks, vasculitis
• Assess volume status - skin turgor, pulse, BP (lying and standing), JVP, lungs (crepitations, pleural rub), SOA.
• CVS - pericarditis, SOA.
• Abdomen - enlarged kidneys (polycystic kidneys, tumour, infiltration). Renal bruits, bladder, prostate.
• Neurology - asterixes, confusion, coma, peripheral neuropathy.
• Fundoscopy - diabetic/HT changes.
• Spine - spina bifida/laminectomy.

• BP, fluid overload, skin (dry, scratch marks), uraemia fetor, asterixis, pericardial rub, CT disease (rash, arthritis), palpate the kidneys, listen for renal artery bruit.

Question 3

What investigations would you carry out on this patient?

Answer 3

• Urine dipstick.
• Urine MCS.
• FBC, iron studies.
• UEC.
• Calcium, phosphate, albumin (LFTs)
• eGFR.
• BSL/HbA1c.
• Coeliac Ab - anti-gliadin, anti-tissue transglutaminase.

Question 4

What investigations would you carry out on this patient?

Answer 4

• Urine dipstick.
• Urine MCS.
• FBC, iron studies.
• UEC (urea, electrolytes, creatinine AKA renal function tests).
• Calcium, phosphate, albumin (LFTs)
• eGFR.
• BSL/HbA1c.
• Coeliac Ab - anti-gliadin, anti-tissue transglutaminase.

• Second line: Renal USS.

Question 5

What treatment does this patient require?

Answer 5

• Referral to urologist.