STEP 2 CS case 2 Hematuria AND OTHER URINARY SYMPTOMS

History
B FUN HIDE PPPISSS
Burning - do u have any burning sensation during urination
Frequency- how often do u have to urinate
Urge- do u feel as though u have very little time to make it to the bathroom once u have the urge to urinate
Nocturia- do u have to wake up  at night to urinate
Hesitancy- has thr been any difficulty urinating
Incomplete emptying- do u feel u havent completely emptied ur bladder after urination
Dribbling-do u have any dribbling after or during urniation?
Episode in past- do u have similar episode in the pasT?
Pain CVA/Urinate- do u have any back pain? do u have any pain during urination
Pyuria- do u have any pus in ur urination?
Past prostate exam- have u had previous prostate examination?
Incontinence- do u any problem controlling ur bladder? does laughing ,sneezing,runnning make it worst?
Stone history- do u have previous history of kidney stones?
Stream- have u noticed any weakness in ur stream?
strain-do u need to strain or push during urination?
STD hx?-have u had  any sexually transmitted disease before?

DOC PA FAA
description of events
Onset
Constant/intermittent
Precipitating event
previous ep?
progression- was this sudden or does this happens over  a period of time ?
associated symptoms? - weight loss,appetite change nightmares?fever,night sweats,chills?constipate ,diarrhea?sob?pain in joints?bowel problem?N&V
aggravating factors?

ROS-THEN FR CS PUB SAW ID 

TRAVEL RECENTLY? trauma?

Headache

Edema

Nausea/vomit

Fever/chills/night sweat

Racing of heart?rash?

Chest pain? / Cough?

SOB

Pain in the joint?

Urinary problems?

Bowel problem?

Sleep pattern(insomnia? pillows to sleep?)

Apetite?

Weight changes?(how much? time?intentional?

Infection (recent?)

D izzy? (if yes,vision problem?)

PAM HUGS FOSS 
PMH-have u had any other major illnesss?
allergies- do u have any drug allergies?
medication- are u taking any medication?
hospitalize?- have u ever been hospitalize?
Urine? have u noticed any change in ur urinary habits?
Gi? have u noticed any change in ur bowel habits?
sleep pattern? how u notice any change in ur sleep pattern?
Family history? is ur parents well and alive?
sexual hx- now im going to ask about ur sexual health and practice,i promis evrything we discuss today is confidential. are u sexually active?with men,women or both? do u use contraceptive?have u had any sexually transmitted disease?
social history -WHARTED:
work?what type of work do u do?
Home? do u live alone?
Alcohol? do u drink alcohol? how much do u drink?
Recreational drug? dou use any recreational drug such as cocaine,marijuane?
Tobbaco? DO u smoke?how many pack per day? how long did u smoke?
Execise? do u exercise?how many time per weeks? how long each section?
Diet? any specific diet are u following right now?


PHYSICaL examination:
CV and pulmonary exam ausculatate
abdominal exam - auscultate palpate percuss,check for cva tenderness
extremities. inspection

differential diagnosi  for hematuria -HITTERS
hematological or coagulation disoder
Infection (UTI)
Trauma
Tumour (BPH,prostate,bladder,RCC)
Exercise
Renal ds(GN)
Stones

Diagnostic workup:
genital exam
rectal exam
cytoscopy
U/S-renal
UA
CT-abdomen/pelvis
PSA
urine culture
urine cytology
BUN/CR
IVP
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Hematuria case 1:
65y M w painless hematuria. +Heavy smoking. Works as painter.

ddx:

1. Bladder cancer
2. renal cell carcinoma, 
3. nephrolithiasis, 
4. acute glomerulonephritis,
5.  prostate cancer, 
6. coag disorder [FVIII antibodies], 
7. ADPKD

W/U: 
GU exam, U/A, urine cytology, BUN/Cr, PSA, CBC, PT/PTT, cystoscopy, U/A-renal/bladder, CT-abd/pelvis, IVP

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Hematuria case 2:
35y M w painless hematuria. +FHx kidney problems.

ddx :

1. ADPKD
2. nephrolithiasis, 
3. acute glomerulonephritis [IgA nephropathy], 
4. UTI, 
5. coag d/o, 

W/U:
 GU exam, U/A, BUN/Cr, PSA, CBC, PT/PTT, U/S-renal, CT-abd/pelvis, IVP

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Hematuria case 3:
55y M w flank pain and hematuria w/o dysuria. +Wt loss and fever x2mo.

1. Renal cell carcinoma
2. bladder cancer, 
3. nephrolithiasis, 
4. acute glomerulonephritis, 
5. pyelonephritis, prostate cancer)

W/U: GU/rectal exam, U/A, urine cytology, BUN/Cr, PSA, CBC, PT/PTT, U/S-renal, CT-abd/pelvis, IVP

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OTHER URINARY SYMPTOMS 

CASE 1 

60y M w/ nocturia, urgency, weak stream, terminal dribbling. No wt loss, fatigue, bone pain. Hx 2 episodes of urinary retention requiring catherization.

DDX:

• BPH
• prostate cancer, 
• UTI, 
•  stones

WORKUP:

- rectal exam, U/A, CBC, BUN/Cr, PSA, U/S-prostate [transrectal]

CASE 2

71y M w/ nocturia, urgency, weak stream, terminal dribbling, hematuria, lower back pain x4mo. Hx wt loss and fatigue.

 DDX:

• Prostate cancer
• BPH, 
• renal cell carcinoma, 
• UTI, 
• bladder stones
   

W/U:

 rectal exam, U/A, CBC, BUN/Cr, PSA, U/S-prostate [transrectal], CT-pelvis, IVP

 CASE 3 :

 18y M w burning sensation during urination and urethral discharge. Recent unprotected sex w new partner.

DDX:

• Urethritis( F+U+B+D+Dicharge)
• cystitis,(F+U+D)
• prostatitis(F+U+D+tender prostate)

W/U: 

GU/rectal exam, U/A, urine cx, urethral discharge Gram stain and Cx, G/C PCR

CASE 4 :

45y diabetic F w dysuria, urinary frequency, fever, chills, nausea x3d. PE: + Left CVA tenderness.

DDX:

• Acute pyelonephritis
• nephrolithiasis,
•  renal cell carcinoma, lower UTI [cystitis, urethritis])

W/U: 

U/A, urine culture & sensitivities, CBC, BUN/Cr, U/S-renal, CT-abd

CASE 5:

55y F w urinary leakage s/p exercise. Loses small amount when coughs,laughs,sneezes. + Low back pain. Hx multiple C-sections. +FHx in mother s/p menopause.

DDX:

• Stress incontinence
• mixed incontinence, 
• urge incontinence,
•  overflow incontinence, 
• functional incontinence, 

W/U: 

CBC, electrolytes, glucose, U/A, urine culture, BUN/CR, urodynamic testing, IVP, cystourethroscopy

CASE 6 :

33y F w/ urinary leakage. Unable to suppress urge, loses large amount w/o warning. Hx UTIs. FHx DM. Drinks 8 cups of coffee/d. Under stress since sister died months ago.

DDX:

• Urge incontinence
• mixed incontinence,
•  stress incontinence, 
• overflow incontinence,
•  functional incontinence, 
• UTI, DM

W/U: 

CBC, electrolytes, glucose, U/A, urine culture, BUN/Cr, urodynamic testing, IVP, cystourethroscopy