Internal Dx II

July 7, 2003

History
- A.M.P.L.E.
- O.P.P.Q.R.S.T.
- H.I.S.T.O.R.Y.

Physical Examination
- Inspection
- Auscultation (done before palpation to avoid changing bowel sounds)
- Percussion
- Palpation

Pictures
- Pitting Edema
o Renal failure most probable cause of death
o Maybe CHF
- Clubbing
o Enlargement of the terminal tuffs (seen on x-ray)
o AKA: Hypertrophic Osteoarthropathy
 M/c lung disease but
 Can be associated with GI and GU problems

A.M.P.L.E.
- Allergies
- Medications
- Past Medical History
- Last Meal/LMP (onset)
- Events of the present illness

O.P.P.Q.R.S.T.
- Onset
- Provocative
- Palliative
- Quality
- Radiation/Region of pain
- Setting/Site/Severity
- Timing (when does it happen and how long does it last)
Picture
- Large smooth dome-shaped mass in the LUQ
- Appears pale over lesion
- Have pt do a sit up so that abdominal muscles contract
- Incisional Hernia (past surgery)
o Gets larger when she bears down and painful
o Auscultation will hear bowel sounds
o Feels like it is filled with air (like balloon)
o Very mobile
o When blood supply is lost to a hernia is call strangulation
- *

HISTORY
- Hospitalization
- Injuries/Immunizations
- Sugar Diabetes
- Tumors/Trauma
- Operations
- Review of Systems
- Youth Illness

Note: EVERY Patient needs a PMH (past medical history) form filled out – MAJOR
CYA to avoid lawsuit.

10-Day rule
• Can only take X-ray’s first 10 days of cycle
• Unless chance Mom’s life is in danger or severe morbidity

Pysical Examination

Inspection
- Symmetry, size (distension), shape
- Lumps, bumps, scars (pt. w/always have bear down to look for hernia),
ecchymoses (bruising)

Auscultation
- Bowel sounds (5-35/minute)
o AKA: Borborygmi
o Relatively high pitched  use diaphragm
o Very high pitched and get faster than 35/minute sign for obstruction
o No bowel sounds  Paralytic (Adynamic) Ileus (blunt trauma, post
operative)
o Early bowel obstruction  Rapid sounds to force fecal bolus
o Late bowel obstruction Shuts down and patient vomits (no bowel
sounds)
o Adynamic Illius → no bowel sounds b/c no peristalsis
 - Bruits
o Swishing Noise
o Caused by turbulent flow (change in speed of blood flow)
o Occurs with aneurysm and stenosis
o M/C in the aorta (infrarenal AAA)

Percussion
- Liver, spleen, diaphragm
o Size
o Diaphragmatic Excursion
o Note pitch
 LUQ: Not eaten  tympanic (b/c air in the stomach)
Eaten  dull
o Spleen: dull
o Liver: dull
o Rest of the abdomen: resonance
o Bowel obstruction: dull
 Tympanic: proximal
 ? : distal

Palpation
- Organomegaly
o Hepatosplenomegaly
 Caused by sickle cell, etc..
- Aneurysms
o Start in non-tender quadrant and go to tender quadrant
o Superficial mass: in abdominal wall
o Contraction of abdominal mm
 Accentuated: in abdominal wall
 If not in abdomen
o If mobile: better than mass that is non mobile
 Malignant masses do not move b/c not encapsulated and they
invade other tumors and inflammatory tumor that makes scar tissue
and makes more immobile
 Benign tumors grow in the original tissue and do not invade
- Palpation of organs
o Liver
o Spleen
- Aorta
o Lateral pulsation is not good, could represent AAA
o 3.5 cm or less is normal size of aneurysm
o AAA produce non-mechanical back pain
Abdominal Exam Tips
- Comfortable room temperature
- Patient gowned with abdomen exposed
- Groin uncovered with genitalia draped
- Bladder empty
- Start in non-tender quadrant (end up in the tender quadrant)
- Use your hand over patients if ticklish (use little firmer touch)
- Normal kidney is non-palpable (possible in thin patient)
- Normal liver may be palpable (8-12cm in height @ Mid Clavicular line)
o Most common cause is alcoholism
- A palpable spleen is enlarged
- When abdomen is involuntarily flex and is very hard → abdominal rigidity
usually caused by peritonitis

Abdominal Regions
- 4 quadrants
o Right upper
 Right kidney
 Gallbladder
 Right renal artery
 Transverse colon
 Biliary tree
 Biliary aa & vein
 Pancreas (Head of)
o Left upper
 Left kidney
 Splenic Flexure
 Stomach (fundus)
 Spleen
 Tail of the pancreas
 Left renal aa
 Aorta
o Right lower
 Ascending colon
 Small intestine
 Right ovary
 Right kidney
 Lower portion of liver
 Right common iliac
 Cecum
 Appendix
 o Left lower
 Descending colon
 Sigmoid colon
 Left common iliac vein
 Small intestine
 Left kidney
 Inferior mesenteric artery
 Left ovary
 Left fallopian tubes
 uterus

- 9 regions
o R/L hypochondriac
o Epigastric
o R/L lumbar
o Periumbilical
o R/L pelvic
o Suprapubic (AKA Hypogastric)

- 6 regions
o Epigastric
 Duodenum
 Pylorus
 Liver (left lobe)
 Pancreas
 Ascending colon
 Aorta (Celiac trunk, renal aa. & veins)
o RUQ
o LUQ
o RLQ
o LLQ
o Suprapubic

Abdominal Exam Tests

- Rebound tenderness
o Push in an area where there is no pain and then quickly let go and pt will
feel pain in a quadrant other than where you pushed (classic is appendix)
o Peritonitis (Rovsing’s Sign) → push in quadrant pain and hurt in same
area
o Pain with recoil palpation
 If pain in another quadrant then the test is positive
• Peritonitis
 If pain in RLQ and doing test in a LQ than can be positive for
appendicitis
-
 CVA (costovertebral angle) tenderness
o Kidney disease
o AKA- kidney punch or Murphy’s punch test
- Shifting dullness
o Done while palpation abdomen
o Ascites
o Fluid shifts in different positions
o For small amounts of ascites called “Puddle Sign”
 Pt on all fours for ~ 5-10 min
 Start out to in and when run into dull mark
 Move to different side and repeat
 Will end up with outline of the “puddle”
- Psoas sign
o Appendicitis
o Resisted right hip flexion (supine)
o Put knee and hip in flexion have pt try resist as Dr tries to extend leg
- Obturator sign
o Appendicitis
o Resisted internal right hip rotation

Diagnostic Imaging
- Barium swallow
o Uses barium sulfate → thick chalky substance
o Shows up very white on radiograph
o Can do upper GI study with a small bowel follow through
- Barium enema
o Barium or barium with air → forces barium against the wall
o Shows endothelial wall in detail
- CT scan with contrast
o Iodine based is injected by IV
 Vascular tissues
Barium
- MRI scan with contrast
o IV contrast
o No real good for hollow organs
- Endoscopy
o Use of flexible fiber optic microscope
o From top EGD (Esophagogastroduedenoscopy) very common
o From bottom Anoscopy, Rectoscopy, sigmoscopy, colonoscopy
 - KUB (Kidney Ureter Bladder)
o X-ray of abdomen (upright and supine)
o Cheapest and quick
o Not a great tool
o Helps see fluid lines
o Helps see if a mass is moving around
o M/c lesion: calcified lymph node
 Follow lumbar or iliac chain
 Can also find in mesentery and momentum

Common GI S/SX
 Abdominal distension
 Abdominal pain
 Anorexia
 Belching, bloating, flatulence
 Bleeding
 Constipation/Diarrhea
 Nausea/vomiting
 Heartburn/indigestion/dyspepsia
 Hepatomegaly/splenomegaly
 Hernias
 Hiccoughs
 Jaundice
 Rectal Pain/itching

Abdominal Distension
- Mechanical Obstruction (inside or outside lumen a hollow viscus that physically
causes obstruction of fecal matter moving through the viscus)
o Neoplasm (intraluminal/extraluminal) (not found usually until late)
 Extraluminal
• Baby
• Hernia
• Abscess from appendicitis
• Oviarian tumor
• Uterian tumor/mass
o Post-operative adhesions
o Abscess
 Appendicitis
 Chron’s
 Diveritculitis
 o Pregnancy
o Hernias
o Volvulus
 Secum
 Sigmoid
o Intussception
 Adhesions
 Paralyzed persons (bowel doesn’t work as well)
 Kid’s maybe hypermobile bowel (not really sure though)
 Trauma
 Ischemia

- Non-mechanical Obstruction
o Adynamic illius(immobile bowel)
o Ascites
o Excess gas
o Trauma (set-belt injury)
o Infection
o Peritonitis

Take KUB (kidney, ureters, bladder) x-ray as a start of diagnosing abdominal problems

5-19-03

Abdominal Pain
- Burning (sometimes described as gnawing)
 PUD
 GERD
 Can be caused by nicotine, alcohol, mint
 Can also be cardiac disease
- Cramping usually from organ distension)
 Biliary colic (gall bladder disease – esp. gall stones)
 IBD
 IBS
 MESENTERIC ISCHEMIA
- Colicky (crescendo – decrescendo pain pattern)
 Renal stones (also called renal colic)
 Biliary colic (gall bladder disease – esp. gall stones)
 Appendicitis
- Achy
 Constipation
 Appendicitis (early stages)
 AAA (saccular)
 - Knife-like (usually very serious)
 AAA (dissecting/saccular rupture)
 Pancreatitis (stabbing in the mid back)
- Sudden onset
 Perforation
 Obstruction
 Pancreatitis
 Rupture ectopic

Abdominal Pain patterns

Diffuse – visceral pain b/c secondary to organ problem

- Early appendicitis
 Diffuse (whole belly) or periumbilical pain
 After 12 – 24 hours pain becomes the very sharp ½ way b/w ASIS
and symphysis pubis
 Rebound tenderness with pain in RLQ (24 – 36 hours)
 Very high fever
 No pain after rupture (80 – 90% mortality)
- Organ involvement
- AAA
- IBD
- Peritonitis – if diffuse peritonitis not focal peritonitis
- Trauma
- Obstruction

Focal
- Parietal pain
- Organ distension
- Peritonitis

Epigastric
- PUD (peptic ulcer disease)
- Gallbladder disease
- Hepatic disease
- Cardiac disease
- Pancreatitis

RUQ
- Biliary tree disease
- PUD
- Pancreatitis – tall end
- Renal disease
- Cardiopulmonary disease
LUQ
- PUD
- Pancreatitis
- Splenic disease
- Renal disease
- Cardiopulmonary disease

RLQ
- Late appendicitis
- Crohn’s disease
- Obstruction
- Reproductive disease
- AAA

LLQ
- Diverticulosis/itis
- Obstruction
- UC
- Reproductive disease
- AAA

Periumbilical
- Obstruction
- Early appendicitis
- AAA
- Mesenteric thrombosis
- Pancreatitis

Don’t learn percentages know what is more common (top 3 – 4 causes)

- Non-specific abdominal pain 35%

- Acute appendicitis 17%
- Intestinal obstruction (esp. if previous surgery) 15%
- Urological causes 6%
- Gallstone disease 5%
- Colonic diverticular disease 4%
- Abdominal trauma 3 3%
- Abdominal malignancy 3%
- Perforated peptic ulcer 3%
- Pancreatitis 2%
- Ruptured AAA <1%
- Inflammatory bowel disease <1%
- Gastroenteritis <1%
- Mesenteric ischaemia <1%
Abdominal Aortic Aneurysm
• Any pt with low back pain over forty you should listen the abdomen for bruits
- Focal widening >3.5cm
o 2-2.5 cm normal size aorta
- > 60 years; M:F = 5:1
- Infrarenal (90%)
- Extension into iliac arteries (66%)
- Plain film: mural calcifications (75-90%)
- CT: perianeurysmal fibrosis (10%), may cause ureteral obstruction (secondary to
AAA)
- US: 98% accuracy in size measurement
- Angio: mural thrombus (80%)
o W/in wall of aneurysm is a clot
- Complications:
o Rupture (25%): into retroperitoneum (usually left), GI tract, IVC
o Peripheral embolization (unusual) (can lose a leg or have severe atrophy)
o Spontaneous occlusion of aorta (caused by spasm)
- Non-mechanical low back pain and patient cannot find a position of comfort and
when pain ends the rupture has probably occurred (if it is leaking it will cause
pain)
- No history of trauma
- No pain relief with analgesics
- Usually found on lateral lumbar X-ray (usually below renal arteries) (infrarenal)

Saccular AAA
- Most common
- Can hear bruits

Dissecting AAA
- Patients are extremely sick
- Usually die within 10 hours
- Bleed to death inside the vessel walls
- Does not widen the aorta very much
- Thoracic AAA are usually caused by trauma
- Lumbar more commonly in elderly (may see calcifications)
Abdominal Aortic Aneurysm
- S/Sx
o Most are asymptomatic (saccular)
o Pulsating sensation in the abdomen
o Abdominal pain (unchanged by position)
o Low Back Pain (unchanged by position)
o Bruit
o Radiating pain into legs
o Cold lower extremities, peripheral pulse loss
o Shock
o Sudden death
- Imaging
o Plain films – can see 75% of AAA
o MRI
o CT

- Treatment
o 3.5-5 cm – careful observation
o 5-7cm – elective surgery (10% rupture/year)
o >7cm – non-elective surgery (25% rupture/6 months)
o If symptomatic → non-elective
- Surgical procedures
o Open laparotomy
o Endoscopic stent placement
- < 50% with rupture survive
o Once ruptures you have minutes to a couple of hours to live

Anorexia (unwillingness to eat because of being sick)

- Infection
- Neoplastic (particularly malignant)
- IBD (Inflammatory Bowel Disease)
- Constipation
- GERD (Gastroesophageal Reflux Disease)
- PUD (Peptic Ulcer Disease)
- Swallowing disorder

Picture of patient
- Patient has anorexia, cachexia (muscle wasting typically from malignancy), and
ascites
- Patient has end stage metastatic cancer
Belching, Bloating, & Flatulence
- Aerophagia  swallowing of air (most common reason)
- Insoluble carbohydrate ingestion
o Bacteria acts on and causes different kinds of gases
 CO2, methane, etc…
- Malabsorption Syndromes
- Lactose intolerance
o Lack the enzyme lactase used to digest lactose
- Diarrhea

GI Bleeding
- Upper GI
o Ligament of Treats – Suspensory ligament of the duodenum @ the duo-
jejunum junction → junction between the upper and lower GI
o Esophageal varicies (dilated esophageal veins)
 Causes by portal hypertension
 Classically causes coffee ground emesis
o Esophageal cancer
o Esophagitis
o PUD (Peptic Ulcer Disease)
 Usually coffee ground appearance
o Gastric Cancer
o Hiatal hernia
 Fundus of stomach loops up toward esophagus
o Swallowed hemoptysis
 Coughing up of blood from respiratory tract infection
o Hematemesis
 Vomiting of bright red blood
• If bleeding in the mouth esophagus or acutely in the
stomach
 Acute upper GI bleed above the stomach or massive GI bleed into
the stomach
• Think esophageal disease
o Coffee ground emesis (special type of hematemesis)
 Coffee ground appearance
 Blood as been around long enough for stomach acids to denature
the proteins
- Lower GI
o Mesenteric Thrombosis
 Thrombosis of mesenteric vascular that results in necrosis
 More proximal to aorta the more serious
o Meckel’s Diverticulum
 No pain but lots of bleeding
o Volvulus/Intussception
 Volvulus  Portion of valve twists upon itself
 Intussception Part telescopes on itself
o Colon Cancer
o Colonic Polyps
o IBD (Crohn’s, UC)
o Diverticulosis/itis
o Hemorrhoids*
 Varicose veins in anus
 Most common cause of bleeding from the rectum
 BRBPR (Bright Red Blood Per Rectum)
o Anal Fissures
o Hematochezia
 Bright red blood in the rectum
 95% from colon (sigmoid)
 Most common cause is hemorrhoids
o Melena
 Black tarry stools
 Enzymes have worked on the stool to make it look black
 Upper or Lower GI bleed that is chronic in nature that the patient
has not vomited up
o Blood streaked stool
 Something inside the lumen of the colon that is bleeding as feces
passes by it
 Usually means blood is more distal because it is still red
 If proximal bleed the blood would get mixed in and the stool
would not be streaked
o Occult blood
 Cannot be seen
 Polyps or cancer
 Detected by occult blood testing  Hemoccult or fecal occult
blood test or guiac stool test
• Must have 3 normal tests to rule out bleeding
• 3 positive should be followed up on
Constipation/Diarrhea
- Constipation  Decrease in the volume of stool
o Fecal Impaction
 Loss of movement of fecal bolus in the colon
 Caused by obstruction
 Feces becomes very dry and very hard
o Poor Fiber Intake
o Poor Fluid Intake
o Colon Cancer
 Pure constipation  obstruction
 Alternating constipation and diarrhea (floods with water to try to
get rid of constipation so causes diarrhea and then constipation
because stops producing fluid)
o IBD
o Psychiatric Causes
o Meds
o Hemorrhoids
o Most common cause is probably poor bowel hygiene
 Not eating enough fiber or drinking enough water

- Diarrhea
o Infection
 Viral gastroenteritis (stomach flu)
 M/C cause
o IBD
o IBS
 Spastic Colon
o Stress
o Colon Cancer
o Psychiatric Causes
o Meds
 Parasympathomemetics (stimulate Parasympathetic)
o Increase in volume of loose stools
o Controlled by parasympathetic, increase in activity causes increase
peristalsis
Nausea and Vomiting
- Infectious Gastroenteritis → stomach flu
o M/c reason
- Obstruction
o Proximal obstruction (small intestine and up) usually causes
o Picture: Volvulus of sigmoid colon
- Pregnancy
- Severe pain
- Cardiovascular Disorders
- Meds
- PUD
- GI Cancer
- Psychiatric Disorder

Heartburn, Indigestion (dyspepsia or upset stomach)

- Gastritis
o Overindulgence, eating too much food, fatty meal
- GERD/Reflux
o Fatty food
o Permanent Damage  permanent scarring = Reflux Esophagitis
- Excess Intestinal Gas
- Gas Entrapments (hepatic/splenic flexures)
- Picture: Esophagus and Stomach (Hemorrhagic Gastritis)

Hepatosplenomegaly

Hepatomegaly
 Cirrhosis
o Most common cause is alcoholism → alcoholic hepatitis → cirrhosis
o Most common cause of hepatomegaly
o It takes 70 – 80% of damage to liver to start to see symptoms
 Hepatitis
 Pancreatic CA
 Hepatobiliary CA
 Cholangitis
o Inflammation of the bile ducts
o Associated with a Charcot’s triad
 Late right-sided CHF
 Infectious mono
o Epstein Bar virus
 Lymphoma
 Leukemia
o Affects younger kids and older people
Splenomegaly
 Anemias
o Not basic iron-deficiency but the more serious anemias
 Infectious mono
 HIV
 Leukemia
 Lymphoma
 Myeloma
o Cancer of the bone marrow (plasmocyts)
o Multiple myeloma is the most common primary bone tumor
 Polycythemia vera
o Severe over production of blood cells

Hernias
 Groin
o Inguinal (96%)
 Direct
 Indirect
o Femoral (4%)
 Occur in women in femoral triangle
 Umbilical
o Usually in pregnant women
 Incisional
 Hiatus

Hernia examination in men

 Fingertip at most dependent portion of scrotum (bottom)
 Invaginate scrotal wall to external inguinal ring
 Gently insert finger into canal along spermatic cord
 Move finger laterally and cephalad
 Pt coughs, strains or performs Valsalva maneuver
 Findings
o Should not feel anything
o Inguinal Hernia
 Small indirect hernia may slightly tap end of finger
 Large indirect hernia may be palpable as mass
 Direct inguinal hernia may be felt on pad of finger
o Spermatic cord tenderness (Funiculitis)
o Spermatic cord lipoma
o Hydrocele
Hernias

 Indirect inguinal hernia

o Most common type, m=f
o Through deep (later)(internal) inguinal ring (entrance to canal)
o Touches fingertip on examination
 Direct inguinal hernia
o M>F
o > 40 y/o
o Through (superficial)(medial) external inguinal ring (exit canal)
o Touches side of finger on examination
o Easily reduced, rarely enters scrotum
 Femoral hernia
o Least common, elderly, F>M (3:1)
o Through femoral ring/canal
o Often asymptomatic (even strangulated), but can be very painful

Hiccoughs

- Rapid spasm of the diaphragm

- Transient
o High emotion
o Temperature change
o Gastric distention (overeating, alcoholism)
o Alcohol Ingestion
o Drinking and eating at the same time
o Smoking
- Persistent
o Uremia (Urea in the blood  sign of kidney failure),
o Hyperventilation (use bag to increase C02)
o IDDM (b/c diabetic neuropathy)
o Meds (steroids, barbiturates)
o General anesthesia
o Thoracic disorder (pneumonia, CA, pleural effusion, pulmonary fluids)
o Gastric disorder (PUD, CA, GERD)
Jaundice

- Yellow color of the skin and sclera because of the build up bilirubin
- Can cause uncontrolled itching
- Direct Bilirubin
o From Liver
o Extrahepatic obstruction (outside liver)
 Calculi, neoplasm, stricture (of collecting duct system from a
tumor or passage of a stone)
 Metastatic CA, pancreatic CA (in head of the pancreas)
o Hepatocellular disease
 Hepatitis (alcoholic and non-alcoholic form)
 Cirrhosis
o Meds (eg. Estrogen)
o Jaundice of pregnancy (hormonal cause)
- Indirect Bilirubin
o Away from liver
o Hemolysis
 Congenital anemias (sickle cell)
 Acquired anemias
o Poor marrow production
o Neonatal Jaundice (treatment by putting under UV light)
o Impaired conjugation of bilirubin from meds

Rectal Pain and Itching

- Hemorrhoids (m/c organic cause  dilated rectal veins (varicose veins of butt) 
internal/external)
- Anal Fissure (babies, people with chronic constipation/ diarrhea, anal sex,
Crohn’s, UC, etc)
- Fecal Impaction
- Prostatitis
- Pelvic Inflammatory Disease
- Endometriosis

END GI MATERIAL
GU Signs and Symptoms

- CVA (costovertebral angle) pain

- Dysuria
- Polyuria
- Urethral discharge
- Impotence
- Hematuria
- Oliguria/Anuria
- Pelvic Pain
- Proteinuria
- Scrotal Swelling

- Main partes of GU: kidney, ureter, bladder, urethra

- Functions: Rid of excess fluids, filter things out of the body that are water soluble
- Blood pressure is regulated by kidneys as well as electrolyte balance and
acid/base balance
- Micturition: reflex that tells you to pee
- Common congenital anomalies → renal cyst, double ureters, only one
kidney/ureter

CVA Pain

- Nephrolithiasis (kidney stones  Ca+ based – 80%) – Murphy’s punch test:

kidney infection
- Pyelonephritis → infection of renal pelvis – upper UTI
o Most common from a poorly treated or untreated lower UTI
- Glomerulonephritis (inflammation of glomerulus- aseptic inflammation  post
strep infection)
o This is why pt with strep throat must complete their antibiotics
o Mistaken for kidney stone
- Renal Cancer → AKA: hypernephroma old term – one of the fastest growing
metastasis
- Renal abscess → people with chronic renal disease, diabetics (most common), IV
drug users, patients with TB
- Spinal disorder
Dysuria

- Painful urination
- Cystitis (Urinary Bladder Infection)
o Infasimatacis Cystitis
 Air in the bladder wall
o E. Coli most common bacteria to cause infection
o Diabetics get cystitis a lot
o More common in women
 Urethra is shorter in women – shorter pathway for bacteria
 Wiping from P to A instead of A to P
 Holding the urge to pee
- Urethritis
o Usually infectious
o Causes: Gonorrhea (gonococcal urethritis), Chlamydia (Most Common)
(non-specific or non-gonococcal urethritis)
- Vaginitis
o Inflammation of the vaginal introitus (opening)
 Poor hygiene  Fungal Infection  Candida Albicans (Yeast
Infection)
- Prostatitis
o Bacterial Prostatitis (Septic)
o Septic Prostatitis
 Both very painful
 Can be caused by stones
- Chemical Irritants
o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche,
Deodorant spray
- Urethral Diverticulum
o Outpouching from a hollow viscus in the ureter (rarely urethra)
 Can become infected and cause pain
 Can be from high pressure in the system (stone), congenital
weakness in the wall
- Bladder CA
o Usually asymptomatic
o Very aggressive
Polyuria

- Excess production of urine

- Relative term compared to how much pt used to produce
- Cystitis/ Lower UTI
o Heightens micturation reflex
- Upper UTI
- Diabetes Mellitus
o Glucose changes the osmolality of the blood
o Patient pees a lot
o Triad:
 Polyuria
 Polyphagia
 Polydipsia
- Diabetes Insipidus
o Lack of anti-diuretic hormone which causes more diuresis (excess
production of urine)
- Meds (diuretics)
o Blood pressure control, congestive heart failure (increase in volume
lowers ejection volume)
- Anxiety
o Got to pee when you get nervous
- Hypokalemia and other electrolyte imbalances
o Low serum potassium level

Urethral Discharge

• Fluid from the urethra when not urinating

• Can be bloody, clear, pus, can have an odor
• Prostatitis
o Bacterial Infection (septic and aseptic)
o Prostatic fluid and/or WBC
• UTI
o Milky discharge (composed of pus)
• Interstitial Cystitis
o Most common in Diabetics
• Vaginitis
o Yeast infection
• Gonococcal Urethritis
o “The clap”
• NGU- Nongonococcal urethritis (Chlamydia)
o M/C STD
Impotence (Erectile dysfunction, Ejaculatory dysfunction)

- Inability to attain or maintain an erection

- Autonomic NS controls erection  parasympathetic controls or maintains
erection  sympathetic (stress) keeps from getting erection
- Psychogenic
o M/C cause of impotence
o Stress
- Diabetes Mellitus
o M/C other than psychogenic
o Poor blood supply
o Micro neuropathies & Micro vasculopathies
- Vascular Insufficiency
o Smokers
- Medications
o Parasympatholytic and Pathomimetic
- Neurologic disease
o Quadriplegic, Paraplegic, Cauda Equina Syndrome, Cancer, Chronic heart
Disease
- Systemic disease
- Prostatectomy
o Cut regional nerves

Hematuria

- Two types
o Gross
o Microscopic
- M/C causes is menstruation
- Painless has worse prognosis (CA, don’t notice, chronic)
- T.I.C.S.
o Trauma
 Renal damage
 Severe Exercise
o Tumor
 Bladder Cancer
 Renal cell carcinoma
o Infection
 Glomerulonephritis → infectious and noninfectious
• Secondary to strep throat
 Pyelonephritis
• Infection of the kidneys
 o Calculi
 Kidney stones
• Calcified stones (gallstones made with cholesterol)
• Form b/c of stasis in system that slows the urine down
o Cysts (renal)
 Over 50% of population has renal cysts
o Surgery
o Sickle Cell Disease (Ischemia, Infarction, and Infection)
 Due to abnormally shaped RBC

Oliguria/anuria

• Reduced/failure to urinate
• < 300 ml = anuria
• < 600 ml = oliguria
• Renal failure = DM
o TX: dialysis, transplant
• Kidney failure = uremia
o Affects BP, acid/base balance, electrolytes
• ↓ fluid intake = usu oliguria
o can only go w/o fluid for 48-72 hrs
• Strenuous exercise
• Sweat the most when sleeping (besides exercise)
• CHF can cz renal failure
• Pre-renal failure = m/c not enough blood going to kidneys
• Intrarenal failure = problem in actual kidney Postrenal failure = obstruction past
the kidneys
 Pelvic Pain

- referring anteriorly
- M/c cz = constipation (lt side)
- Pelvis is triangle b/w both ASIS and pubic symphysis
• Dysmenorrhea
o Painful menstruation (outside normal)
o Cz: thyroid problem, infection, premenopause, fibroids, endometriosis
• Fibroids
o Benign tumor of uterus (leiomyoma → smooth muscle tumor with fibrous
tissue)
o Found on plain films of lumbar spine – very common
o Possible to become malignant
o Can be very large → can make women think they are pregnant
• Adhesions after surgery
• Cystitis → m/c cause = e. coli
• Endometriosis
o Abnormal deposition of endometrial tissue outside of the uterus
• IBD → Chron’s, Ulcerative Colitis

Proteinuria

• Not normally in urine b/c it’s too large

• Occurs w/damage to basement membrane
• Malignant HTN → ↑ BP, enough to cz tissue damage
• Idiopathic proteinuria
o Ok if everything else has been ruled out
o Ok if it’s mild
• Nephrotic syndrome → classically associated with proteinuria
o Diffuse swelling associated with proteinuria
o Associated with renal failure
• Malignant HTN
• CHF
• Diabetes mellitus sickle cell disease
• Idiopathic proteinuria
• Pyelonephritis
• Pregnancy
• Myloma
• Leukemia
• Lyphoma
Scrotal Swelling
• Testicular torsion
o Spermatic cord & vessels twist
• Epididymitis
• Trauma
• Hernia
• Tumor
• Varicocele → “bag of worms”, varicose veins
• Hydrocele → fluid filled, tubular cysts

**END TEST ONE**