Week 2 - Lower abdominal pain and anuria

Question 1

Mr. M.R. is a 74y retired carpenter who lives in Ingham. He attends the GP surgery suffering from lower abdominal pain and a history of having not passed urine since the day before.

Take a history of this patient.

• Dysuria, puffy face, backache - 36h.
- Dysuria - infection, stones.
- Puffy face - kidney disorders.
- Back ache - kidney pain if in loin area.
• Lower abdominal pain, suprapubic 8/10, no urine passed since last night.
• Urinary frequency (4-5/day; 2/night); terminal dribbling and hesitancy.
• Poor stream, cannot empty bladder. Urinary urge incontinence.
- Some obstruction. Urge but cannot pass → dribbling.
• Urinary symptoms… months, ‘maybe even a couple of years’.
• No fever, no haematuria, no h/o STD, bit tired, since 2005, diabetes.
• Smoker since age 16, 5-10/day, cough in mornings, early morning erections.
- Early morning erections - significance?
• If erection - normal testosterone, no neuropathy.
• DRE - firm enlarged prostate, suprapubic tenderness (bladder inflammation).

Answer 1

HPC:
• Site of pain
• Onset
• Character of pain
• Radiation
• Alleviating factors
• Timing - experienced before? Constant or intermittent? How long does it last? Worse at a particular time?
• Exacerbating factors
• Severity
• Associated symptoms
• Effect on lifestyle

• Nausea, fatigue, oedema, pallor (acute renal failure)
• Haematuria, dysuria, frequency, urgency. Fever.
• Nocturia.
• Polyuria, polydipsia (diabetes)
• Weight loss, fatigue, loss of appetite (tumour)
• Diarrhoea, frequency (autonomic neuropathy).
• Incontinence, dribbling, retention.
• How long urinary symptoms lasted?
• Erections? Sexual history i.e stricture from past STIs.

PMHx:
• Any past medical history of UTIs, tumours, diabetes, stones, prostate issues.

PSHx:
• Any recent surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment.

Immunisations:
• E.g. Fluvax, pneumococcal.

FHx:
• Any family history of UTIs, tumours, diabetes, stones, prostate issues.

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: mental status, hyperventilation, uraemic fetor, pigmentation (brown tinge), skin nodules.

3. Vital signs:
• BP - hypertension, postural variation.
• HR
• RR
• Temp
• BMI, fluid intake, output chart, urine analysis.

4. Hands/Arms:
   • Nails - leuconychia, Mees lines (renal failure), Muehrcke’s lines (hypoalbuminaemia), half and half nails (CKD), palmar crease pallor, asterixis, scars, AV fistulae/shunts over wrist and forearm, bruising, pigmentation, scratch marks (due to hyperphosphataemia), vasculitic changes (causing renal disease like SLE, systemic sclerosis).
5. Face:
   • Facies associated with SLE and systemic sclerosis, conjunctival pallor, jaundice, band keratopathy and fundus check for diabetic or hypertensive retinopathy.
   • Mouth - ulcers, thrush, hydration, uraemic factor, gingival hyperplasia associated with transplant medication.
6. Neck: scars (parathyroidectomy), vas-cath for haemodialysis.
7. Abdomen:
   • Inspection - scars, presence of a peritoneal dialysis catheter, distension (polycystic kidneys, ascites due to nephrotic syndrome) and visible masses.
   • Palpation - tenderness, renal masses, ballot kidneys, hepatomegaly or splenomegaly (due to cysts associated with polycystic kidneys), presence of an enlarged bladder, abdominal aorta for aneurysm.
   • Percussion - shifting dullness, percuss for an enlarged bladder.
   • Auscultation - for renal artery bruit and abdominal aorta.
8. Back: bony tenderness (osteomalacia, secondary hypertension, multiple myeloma), sacral oedema, scars, renal angle tenderness.
9. Legs: oedema, skin changes as in arms, gouty tophi.
10. CVS/RESP:
    • JVP, carotid bruit (indicate atherosclerosis) and look for signs of CCF and pulmonary oedema, pericarditis, pericardial effusion.
    • Lungs - signs of infection due to immunosuppression from CKD or as a result of treatment.
11. CNS: peripheral neuropathy, myopathy, carpal tunnel syndrome.
12. Rectal exam needs to be performed for scrotal masses and oedema. Pelvic exam for enlarged prostate in males.

Question 3

What is your provisional and differential diagnoses?

Answer 3

• Provisional diagnosis:
• DDx:
- Acute renal failure (nausea, fatigue, oedema, pallor).
- DM + UTI.
- Renal, prostate tumour.
- Urolithiasis.
- DM nephropathy.
- Diabetic autonomic neuropathy.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• U+Es.
• LFTs.
• Clotting.
• CK, ESR, CRP.
• Calcium, phosphate.
• BSL/HbA1c.
• Urine dipstick/MCS/culture.
• Blood culture (if signs of infection).
• Renal USS.